Cigna HMO in GA

I have Cigna HMO. Has anyone used Cinga HMO for WLS what has your experience been and suggestions and tips would be greatly appreciated. Im in the process of submitting all paperwork. I want to make sure all my t are crossed and i's dotted. Thanks

Do you have the six months of a diet with monthly weighins? Be sure that you send in your psyc. eval with the initial paperwork. I was recently denied by Cigna, but I am lucky enough to have UHC as a secondary insurance. Marsha

Hi Tonya, I have Cigna HMo in GA too. I have been denied right now and am appealing. So far I've learned their guidelines state there must be 2 physician supervised diets of 26 weeks with one being in the last year. I had originally seen a physician for open RNY ; however, I'm now reconsidering that type of surgery for a lap surgery or a DS. I don't know how Cigna will handle that if I switch.

Here's some info that might help: BENEFIT EXPLANATION An initial nutritional evaluation and short-term (as authorized by Health Services) nutritional counseling by a Participating Provider is covered when diet is part of the medical management of a documented disease. Short-term evaluation and counseling by a Participating physician or nutritionist includes initial dietary workup and sample menu planning by a nutritionist or physician, and counseling to explain the menus and the dietary impact on the disease or condition to the member/participant. Requests for medical or surgical management of morbid obesity must be evaluated and approved by Health Services and/or the Healthplan Medical Director. Parenteral nutrition (nutrition by some other means than through the gastrointestinal tract, usually intravenous), when it is the only medically necessary means of nutrition must be pre-authorized by the Health Services. Special newborn formula prescribed by the PCP is covered during hospital confinement of the newborn. Special diets ordered or prescribed as medically necessary by the PCP or Participating Provider are covered when provided in an authorized inpatient setting. Non-prescription enteral nutritional formula is not covered (except as outlined in the Flexcare benefit explanation section of this TABS). Prescriptive enteral nutritional formula may or may not be covered as part of prescription drug benefits. The prescription benefit plan should be referenced to determine coverage. Diet centers or diet plans and the associated costs of those programs, or physician visits and laboratory procedures associated with those plans are not covered expenses. _______________________________________________________ BENEFIT INTERPRETATION Medically necessary initial evaluation and short-term counseling (for example, up to 12 sessions in a contract year) for medical management of a documented disease must be pre-authorized. Services may include initial dietary workup and sample menu planning by a nutritionist or physician and counseling to explain the menus and the dietary impact on the disease or condition. Examples of such diseases include, but are not limited to: Anorexia Bulimia Celiac Disease Crohn's Disease Diabetes Liver Disease Malabsorption Renal Failure Ulcerative Colitis GASTRIC BYPASS SURGERY FOR MORBID (SEVERE) OBESITY A measurement of the Body Mass Index (BMI) is an objective measurement which is currently considered the most accurate measurement of excess adipose (fat) tissue. The National Institutes of Health has defined obesity as a Body Mass Index (BMI) of greater that 27.5 kg/m2. Mild obesity is classified as BMI 27.5 - 30 kg/m2; moderate obesity is classified as 30 - 40 kg/m2; and severe or morbid obesity is classified as greater than 40 kg/m2. Body mass index is calculated as weight divided by the square of the height. Weight (kg) BMI = Height2 (m2) OR Weight (lb) BMI = X 703.1 Height2 (inches2) [NOTE: BMI cannot be calculated for client where accurate height measurement cannot be done (e.g., scoliosis, kyphosis, etc.)] Morbidity and mortality is significantly increased in members with severe obesity. The health risks for a BMI of 35 to 40 are considered to be "very high"; the health risks for a BMI of > 40 are considered to be "extremely high". A member with a documented BMI of 40 or greater will generally have one or more comorbidities in most cases. If there is documentation that the member has a significant comorbidity associated with BMI of 35 or greater, the health risk is considered to be "extremely high". In many instances, a modest weight loss can contribute to improved health and improvement of most comorbid conditions. Documentation should be obtained that all members have been aggressively referred for conservative, medical management of their obesity through active participation in professionally supervised weight reduction programs. While not all patients will succeed in these programs, compliance and participation in professionally managed weight reduction programs will document that less intensive medical therapy has first been attempted (which is required under the medical necessity definition for all GSA contracts). In addition, these patients are high risk surgical candidates and are subject to many surgical complications, thereby further requiring documentation of failure of conservative management of their obesity. GASTRIC BYPASS FOR MORBID (SEVERE) OBESITY All of the following medical necessity criteria must be met in order for the member/participant to be eligible for coverage of surgical intervention (gastric bypass) for the treatment of morbid obesity: - A Body mass index [BMI] greater than 40 for at least 5 years; OR - A Body mass index [BMI] between 35 to 40 with additional documentation of one or more clinically significant comorbidities which have failed to respond adequately to non surgical treatment methods including appropriate and adequate medication, e.g., hypertension, gastric reflux, diabetes mellitus, coronary artery disease, pulmonary dysfunction, severe sleep apnea, lower extremity venous and lymphatic obstruction, obesity related pulmonary hypertension, symptomatic osteoarthritis of the knee, hip or back, etc.; - In addition to the minimum weight requirements listed above, there must be history and documentation submitted and reviewed supporting previous weight loss attempts with active participation and reasonable compliance in at least three (3) professionally supervised weight-loss programs for a minimum period of twelve weeks in each program. At least one of the programs should have been completed within the previous twelve (12) months. Each professionally supervised programs should have included weigh-ins on a regular basis, at least monthly. Acceptable weight loss programs include, but are not limited to: - Physician office notes indicating instruction/monitoring on a low/very low calorie diet and/or anorectic medication; - Evaluation/treatment plan from registered dietician for a low/very low calorie diet; - Participation in a commercially available behavioral modification program, e.g., Weigh****chers, TOPS (Take Off Pounds Sensibly), Jenny Craig, etc.; - Participation in self-help group, e.g., Over-eaters Anonymous, etc.; - Participation in structured exercise therapy program under the direction of a physical therapist or exercise physiologist; - Under the care of a psychiatrist or psychologist with expertise in eating disorders ; - In evaluating each case individually, the Medical Director may waive the requirement for participation in one or more weight reduction programs if documentation is presented of an immediate life-threatening comorbidity. The member must be an acceptable age and risk for surgery as determined by Primary Care Physician or Participating physician. Since these patients are by definition, high risk surgical cases, the risk assessment is one of comparing the risks of the various comorbidities with the surgical risks. The medical record should document that consistent reasonable efforts have been made by the primary care physician to deal with the member's comorbidities using standard conservative protocols. Inadequate treatment of a comorbid condition should not be used as an indication for gastric bypass surgery in those members with BMIs between 35 and 40. Review of the member's medical records should show that not only has the member made three attempts at weight loss, but also that the member's primary care physician has made reasonable efforts to control the member's obesity related comorbidites through standard conservative treatment protocols. For example, if the member has hypertension, the record should show that at a minimum two drug step therapy has been given, before concluding the hypertension can't be controlled unless the obesity is dealt with thru surgical means. However, many comorbidities will resist standard conservative treatment protocols unless the obesity is ultimately corrected. Liposuction is not a covered benefit (See Cosmetic TABS) Psychological issues as the sole indication for gastric bypass surgery is not a covered benefit, as it is an inadequate indication for meeting medical necessity criteria. However, psychotherapy and psychoanalysis may have been used as a part of an overall weight loss program and may be submitted as one of the required three professionally supervised weight reduction programs. Formal behavior modification programs including lifestyle changes, have been beneficial in maintaining weight lost in some instances. Such techniques are frequently incorporated into such programs as Weigh****chers. _______________________________________________________ EXAMPLES A member has newly diagnosed diabetes. He would like to take a diabetes class at the hospital which will teach him what type of foods he can and can not eat. Will CIGNA cover the class? - The PCP or Specialist can provide counseling regarding his diabetes during office visits. Additional classes at the hospital may or may not be authorized based on the medically necessary requirements of this individual, and his benefit plan. More clinical information is required to make the determination. A member feels he is about 30 pounds overweight and would like to go to Weigh****chers so he can trim down before summer. He is calling to ask if Weigh****chers is covered. - Weigh****cher programs are not covered. Diet centers or diet plans and the associated costs of those programs, or physician visits and laboratory procedures associated with those plans are not covered expenses. A mother is calling to ask if PKU formula for her infant is covered? - GSA: Formula for PKU is not covered. - Flexcare: Formula for PKU is covered. A PCP is calling to request pre-authorization for his patient to see a dietician at the local Participating Hospital for a cholesterol of 400. He is not overweight, but does not exercise. The PCP has educated the member on exercise and basic nutrition. He would like the patient to see the dietician 5 times over a 3 month period. He will have another cholesterol count in 6 months. - An initial nutritional evaluation and short-term nutritional counseling by a Participating Provider is covered when diet is part of the medical management of a documented disease. Short-term evaluation and counseling by a Participating physician or nutritionist includes initial dietary workup and sample menu planning by and counseling to explain the menus and the dietary impact on the disease or condition to the member. It should be covered for this member. A 49 year old woman was hospitalized last week with a CVA. She was receiving Ensure as a dietary supplement while hospitalized. Her PCP is calling to request coverage of Ensure as a dietary supplement at home. - Special diets ordered or prescribed as medically necessary by the PCP or Participating Provider are covered when provided in an authorized inpatient setting. Nutritional supplements are not covered in the home setting. A 54 year old man with multiple health problems is unable to take oral nutrition. He has a gastrostomy tube and receives nutrition via tube feedings. The nutritional formula used for the feedings can be obtained over the counter. His daughter is calling to ask if the formula is covered. - Non-prescription enteral nutritional formula is not a covered expense. A 45 y.o. male is requesting gastric bypass surgery for severe obesity which he has had for the last ten years. His BMI is 50 and he has severe osteoarthritis of the knees and hips which has failed to NSAID and surgical debridement of the knees. He remains symptomatic and is severely hampered in his work efforts. His history shows he has attempted to lose weight over the past five years through regular participation in Weigh****chers, Jenny Craig and during the last year he received a six month course of Phen-Fen from his PCP with little results. - The patient meets all of the medical necessity criteria for gastric bypass surgery. It is a covered benefit in this case. A 25 y.o. female is requesting gastric bypass surgery for obesity. Review of medical records from her primary care physician shows that her BMI currently is 34. She has no significant comorbidities, but is requesting the procedure because of her concerns with her appearance and the fact that she has been "heavy all of her life". She has tried many diets on her own which she has obtained from various magazines, none under the care of her physician. * This case does not meet the medical necessity criteria: 1) the member does not have documentation of a BMI of at least 35 with significant comorbidities, and (2) she does not present documentation of at least three attempts to reduce her weight with professionally supervised programs. The procedure should be denied as not medically necessity in this situation. _____________________________________________________ "PLAN SPECIFIC PROVISIONS AND ANY APPLICABLE STATE AND FEDERAL LEGISLATION TAKE PRECEDENCE OVER ANY STATEMENT MADE IN THIS MANUAL."