Cigna - 6 Month Weight Loss Documentation (clinical notes)

Good Morning Everyone,

I am so frustrated trying to get the documentation together.   Can anyone who has Cigna as their insurer and has been approved for surgery, give me an example of what was included in their clinical notes?   I've called Cigna several times.  Initially I was told I didn't need 6 months documentation of weight loss.   Any help you can give me would be greatly appreciated.

Judy

I just went through all of this. What my doc submitted had all 6 months listed, my height, weight, bmi, blood pressure and temperature. then there was a brief (BRIEF) description of what we did at each visit. I was following South Beach so it said something like Month 1- "advised patient to begin South Beach diet and begin walking 30 minutes 3 times a week." Month 2 - Patient lost 2 lbs.& has been walking 3 times a week for 15 minutes. Advised to continue south beach diet and plan to walk for 30 minutes.

It was really a brief set of notes. then he wrote a cover to go with it that was basically him saying I was a candidate for surgery and that I had indeed tried for 6 months.

Hope that helps.

- Iris

Thanks so much for the information!

Hi Judy,

We have been doing through this with my husband and he has medicare which is supposed to be one of the toughest. They want the clinical notes to indicate

* Vitals ... Height, weight, BP, anything else

* Discussion of the diet plans for the upcoming month ... i.e., Low carb, reduced caloric intake to X, or any other plan ... could include meds or not. Whatever you have discussed re: dietary guidelines you will follow.

* Discussion of exercise plans for the upcoming month ... i.e., walking 30 mins 3 times a week, swimming 30 mins times a week, etc...

* Discussion of behavior modification plans for the upcoming month ... i.e., attending support groups once month, scheduling a visit with a counselor to discuss issues surround weight gain and how to recognize and change negative behavior.

They wanted to know what the plans are for the next month and what the result of your attempt was the previous month; i.e., lost 2 lbs, weight stable, gained .5 lbs.

For my husband all of this needed to be detailed in the clinical notes and could not be addressed in a letter or other documentation. It can be referenced in a letter from his Dr. suggesting that he would be a good candidate for WLS and indicating that he had tried for x period of months with a weight loss, exercise and behavior modification program, but the 'information' had to be in the clinical notes.

I had my husband get his appointment early in the month and then get a copy of the clinical notes so that we could review them and make sure that they meet the criteria. We have had some issues that had to be corrected or clarified and doing it early in the month allows you to do that and/or schedule a subsequent appointment if necessary.

I know that this can really be a pain, but it's the only way I know to be able to get it done and ensure that it's correct. The reason we do this early in the month, is that if there is a problem we want to be able to spot and correct within the month so that he doesn't have a month that isn't properly documented because when that happens the 'clock' starts all over again... We don't want to do that again.

Good luck!

Barb

Barbara,

Thanks for the input.   I'll make sure I get as much detail as possible.

Judy

Barb,

I've got Medicare and while I had heard conflicting stories about whether you actually needed 6 months documentation of medically supervised weightloss before you could apply to Medicare (I've had people tell me you need it, a few swear you don't) I had no idea it had to be that detalied. I haven't been to see my PCP in at least 3 years (last time was to get some paperwork filled out when I was starting college) so I have no idea how familiar he is with what needs to be done and if he's not, I don't have a clue where to start to find a doctor that does and can help me start the ball rolling.

Do you always have to get a referal from a PCP to a surgeon or can I see a surgeon directly? I feel like I know a lot more about the surgeries themselves and not much about how to get to that point!

Shonda

This is what I'm going by.  It's buried somewhere in Cigna's website.  My friend actually found it.  Hope this helps.
Stacey

CIGNA HealthCare covers bariatric surgery using a covered procedure outlined below as
medically necessary when ALL of the following criteria are met:
• The individual is ≥ 18 years of age or has reached full expected skeletal growth AND hasevidence of one of the following:
􀂾BMI (Body Mass Index) ≥ 40 for at least the previous 12 months.
􀂾BMI (Body Mass Index) 35–39.9 for at least the previous 12 months with at least one
clinically significant comorbidity, such as a serious cardiopulmonary problem, Type 2
diabetes, hypertension, coronary artery disease, or pulmonary hypertension that has failed torespond adequately to appropriate medical management.
• Active participation within the last two years in one physician-directed weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of ALL of the following components:
Page 2 of 28
Coverage Position Number: 0051
􀂾Vital signs, including weight
􀂾Current dietary program
􀂾Physical activity (i.e., exercise program)
􀂾Behavioral interventions to reinforce healthy eating and exercise habits
􀂾Consideration of pharmacotherapy with U.S. Food and Drug Administration (FDA)-
approved weight-loss drugs, if appropriate

For individuals with lifelong, morbid obesity, participation in a program within the last five years is sufficient if documentation of six months is available and reasonable compliance with the weightmanagement program over an extended period of time can be demonstrated. However, diet programs/plans alone, such as Weigh****chers®, Jenny Craig® and similar plans, are not considered physician-directed weight-management programs and do not meet this requirement. Similarly, physician-directed programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.
• Recent evaluation by a multidisciplinary team including:
􀂾A thorough medical history and physical examination.
􀂾An evaluation by a licensed mental health care professional that specifically addresses any mental health or substance abuse diagnoses, the emotional readiness and ability of the patient to make and sustain lifestyle changes, and the adequacy of their support system. If an individual is already in behavioral health treatment, consultation with their treating clinicians should also be sought.
􀂾A thorough nutritional evaluation by a physician or registered dietician experienced in the issues of bariatric surgery, who has had a meaningful conversation with the individual regarding the dietary and lifestyle changes required to ensure a successful outcome over time.
http://www.cigna.com/customer

Good Morning Stacey,

Thank you so much for going to the trouble of finding this documentation.   I guess I'll begin my 6 month documentation with the doctor.

Regards,

Judy