Just starting out and already discouraged!

I've been contemplating getting a bypass done for some time now. I finally worked up the courage to call the doctor's office to make an appointment for my first consultation. However, they gave me the insurance code so I could check with my insurance to see if it would be covered. All I got from my insurance ****igna PPO) was "no". That was it - "no". I've read documents on Cigna's website that it is covered, but it just has to be proven to be medically neccessary (why they didn't say this over the phone, I do not know). Has anyone fought their insurance company? I haven't even gone to my first consultation yet, but I don't want to go and get my hopes up if I cannot get this procedure paid for (at least partially). I've seen posts of people writing letters to get approved. I've seen something about it being a law in MD if you're a certain BMI the ins. co. has to approve you. Is this something I have to fight on my own or should I expect help from the doctor's office? I'm really feeling down right now because I was finally excited about getting this surgery and now I don't know if it will happen. Any words of advice would be greatly appreciated. Thanks for letting me vent!

Lisa, Congratulations on your decision to take the first step on your WL journey. Don't be discouraged! Most insurance companies require medical documentation prior to approval of weight loss surgery. I have BCBS and I know others who have various plans and it was the same for them as well....Investigate what the medical critiera are for approval of WLS with your insurance company. They should be able to tell you and/or send you something in writing. I had my first visit with Dr. Li's office (at Sinai) in June and they were able to tell me up front what my insurance company would cover although I had already researched it for myself. Most of the insurance specialists in the physician's office are familiar enough with various insurance companies to let you know what they will and won't cover. But I would still suggest you find out for yourself. Also most of the doctors' office staff are really good with working with the insurance companies to get you approved...so don't give up! Good luck on your journey! Karen

Hi Lisa, first congrats on making a life changing decision. I too HAD Cigna, but mine was POS instead of PPO....they told me that it had to be medically necessary...well, short of being dead, nothing was going to convince them I needed that surgery....I fought it legally....blah blah blah....and as I have said several times on this website...yes, folks tell me that it is against the law for cigna to deny me the surgery, but they did....and even with me and the lawyer pointing this out did not change their minds..... so, I went self-pay....took out a second mortgage on our home...it was the best money I have ever spent!!! And in the beginning of my journey, I had no idea how to pull it off...I was so angry.....but things worked out. Others folks have gotten their insurance companies to give in...perhaps you will be one of the lucky ones.... I am 16 months out, down 120 lbs, basically to goal and now am scheduled for a Tummy Tuck on Sept 19th!! I would do WLS again and again for my life right now...especially to fit into my size 8 jeans....with my tt, I will be wearing a size 6 for sure....I started at 22/24....and btw, I never thought I could ever fit into a size 8, much less a 6. Best wishes to you on your journey! RAE

Lisa, I can't say I've ever heard a good story about people working with Cigna policies, I'm sorry to say. There are several things you need to know and/or understand which may help in fighting your way through this maze. The Maryland law applies to health insurance policies for employers having more than 50 full-time employees, and health insurance contracts that are written and subject to Maryland jurisdiction. The law does not extend to employers with fewer than 50 full-time employees; it also does not apply to Federal employees. Another major exception to the law are the employers having self-funded health insurance policies. A number of the Cigna stories I have heard fall into this category. The self-funded plans mean that the employer actually is the insurer, and the health insurance company is merely the out-sourced administrator. In those cases, the health insurance company is only following the coverage dictated by the employer, in which case you need to go to the employer to pursue approval for the coverage. This often applies to some very large corporations, associations, and labor unions. The self-funded insurance plans are created pursuant to the federal ERISA laws, which is why they're not covered by the Maryland law. If you can find out and share some additional specifics about your health insurance plan, perhaps we can provide some additional support. Good luck. Leesa

I work for a company with more than 50 full-time employees, but it's not so huge that it would actually be the insurer (at least not that I know of). I will double check with HR on that one - thank you for pointing that possiblity out to me. Unfortunately, I don't think a loan is an option for me, so I hope to get this figured out. Like I said, I am just beginning this process so I'm a little lost. I'm hoping the doctor can help me with the specifics, but I know that probably isn't his job. I have a feeling that IF Cigna will help me out, then I will need to provide a lot of documentation which I do not have. It could just be that I'll have to wait 6months - year before surgery is an option. I'll get all of my ducks in a row one way or another. I've waited this long that waiting a little longer won't hurt. I just have to find out how and what I need to do. Thanks everyone for the info!!

Lisa, What you could start doing regarding the documentation is start seeing your primary care physician on at least a monthly basis -- and make it once a month (not every 5-6 weeks). If you have any symptoms of co-morbidities, make sure it shows that you're going for that issue, and not just for weight managment. It's ironic that many insurance companies require physician-directed weight loss efforts as a pre-requisite for insurance coverage, but won't actually cover those doctor's visits. Make certain that when you do go to your doctor, he/she is charting your weight progress, regardless of whether you're actually losing. Good luck. Leesa