I'm About to Give Up!!!!!

Well it seems that Cigna doesn't have my paperwork as they said last week. So I called my surgeon's office to find that they have not been submitted yet. Probably won't be until the end of this week, or first part of next week. This is annoying the heck out of me, to say the least. Six weeks and going on still with just everything sitting. I've also found that I cannot do a resubmit for pre certification but a 2nd level appeal. I was told where to have the paperwork faxed too and for my surgeon to call (they gave me the number) and do a peer to peer again. Since I have redone everything and have new information, my surgeon is allowed to do another peer to peer. Trust me, I wrote the name of the gal telling me this and I've requested a Case Manager to help me with this process. What got me was that I was asked why I needed a Case Manager. Hello.... anyone home in that head she has? lol If I'm denied again, I can do an external appeal OR wait another year and file everything all over again which would be 10/07 OR change insurance as it's open enrollment until 11/15 and I can change over to Aetna and submit everything in January. I'm really at the end of my ropes with this whole process and about to just throw in the towel. I really feel like I do not have a support system with my surgeon's team right now and it's really getting to me. Thanks for letting me vent. Bunny

Hi Bunny Don't give up. It seems like you are almost there. I would not reccommend changing insurance to Aetna. I had that insurance when going through the gastric bypass surgery process. I had my first appointment with Dr. Randall sometime in July or August 2004 and I did not have surgery until Nov. 2005. Aetna requires 6 months of supervised weight loss program. Aetna did except me seeing Dr. Randall every few months, seeing the nut, and the psych. I was hoping to have surgery in the summer of 2005. I don't think Dr. Randall's office sent my paperwork in a timely manner. Once they sent in the paperwork Aenta then sent me a letter ststing they had 45 business days to review and make a decision. I received a letter 3 or 4 weeks later stating I was approved. It was a long process with Aetna as well, maybe not as long as Cigna. Try to keep your chin up and hope for the best. If you get an answer before 11/15 then you will no if you should then change insurance. I am not sure if Aetna will take all your previous things that have already been completed. Good Luck and I will be hoping for the best for you! Janet

Hi Janet: Thanks for the input. Aetna is very similar in their guidelines for WLS and they would take what I have done to this point as it is all current. Both are tough to get this surgery and it seems that Dr. Randall's office is not as familiar with Cigna and Aetna when it comes to submitting for approval. They had no idea that I would have to wait a year from the date of denial to resubmit. How is anyone suppose to know this? I just need to get someone to get off their hiney and get this going. I think 6 plus weeks is excessive. I'm sorry you had such a rough time with this. I started this 7/05 and here it is 10/06 and still nothing. GRRRRRR!!!! Enough is enough already. Not sure what else I need to do. Lorraine

Bunny, How frustrating! I'm sorry you're going through this. I have not even met w/my surgeon yet but I was told that Tufts is very good and easily accepted. I checked their website and it indicates that they approve if the BMI is over 40 which mine is, plus I have hypertension. I wonder if you can't speak to someone at the surgeon's office. It would seem to me that it would be in their best interest to serve your needs since you are their "customer". When I went to the new patient orientation at Newton Wellesley, I kind of got the feeling that it was indeed a "business." I understood the need for the meeting - they gave a lot of information and it makes sense to have folks interested in surgery attend to learn more before they book the surgeon's time.... but at the same time I felt like I was at a Tupperware party, lining up to schedule an appointment. It was almost like an infomercial, where at the end they give you the ordering information! That may not be a great analogy and I do think the surgeons are great and are concerned about their patients. But this is a booming business and there are many surgeons in the Boston metro area. We are lucky to have so many choices. I have read posts from post ops stating stuff like "my doctor is new at this and couldn't answer my questions" which scares the crap out of me. I would never go to a doctor who didn't have a lot of experience but also I wouldn't go to one who did not treat me as a human being. That goes for the surgeon's staff as well. Just keep in mind, worst case scenario, that there are other surgeons in the area. I know your problem is with insurance and not your surgeon but I know there was someone else who switched to NW and they took all the work that had been previously done. Hang in there!! Kathleen

The only way I'll do this surgery is with the surgeon I have. I have an email into him to make sure he's on board with me for the peer to peer and help me fight for this. It's really difficult when I see how busy he is and know that his time is stretched but his attention to his patients, his care, his support and his years of experience make a world of difference to me. My stress is with my insurance. I have other options then just Cigna or Aetna but I know nothing about them. Health Partners is one of them, M Plan and Kaiser California. So my thought is that I really only have Aetna and Cigna. Both are great insurance companies, it's just making sure that the guidelines are all met, which they are now. They were not the first go around but that was me listening to the direction of my nutri telling me who to do this and I missed the point of having to make sure I was guided by my PCP. This time it's correct. Thanks so much for the support, it is appreciated more than you'll ever know. Bunny

hi. i work with a girl who had cigna. she was 350 lbs. this was 4 years ago. she was DENIED i think twice. said she didn't meet the qualifications!!! she had DIABETES, HIGH BLOOD PRESSURE, you name it, she had it. she finally told them that she was getting a lawyer and they approved her in less than a week. now she's switching to BLUE CROSS so she can get the PS. i'm going to Newton Well. and i was at that seminar too. you know, i didn't feel like it was a "business" like the other girl said, but they are surgeons and surgeons like to operate, right? i don't know why she felt like that. we are all in this together. i went to my consult today with Newton W and i feel very excited. i just have to wait for my approval (they say two weeks), i have blue cross hmo and i can schedule my preference for surgery. how cool is that? i'm aiming for the first of january. good luck and KEEP FIGHTING. YOUR WORTH IT.