Cigna - Denied Gastric Bypass - Help - Has Anyone One Else Had this Problem

Good Morning,

I received a letter from Cigna denying RNY.   For 2 reasons - a letter from my Doctor
that my BMI has been 40 or greater for 2 years and a letter from a surgeon qualified to do bariatric surgery recommending surgical treatment.

I would think the letters should not be a problem but I want to make sure I get the type of documentation Cigna wants.   Can anyone tell me exactly what the letter from my Doctors should include?   Cigna is always sooooo very vague when asked this question.  

I would appreciate any help you can give me.  Thanks!

Judy

Hi Judy,

It sounds to me like you have some 'technical' issues that need to be addressed. I would contact CIGNA directly and ask for clarification. Next, I would contact the insurance specialist at Duke and ask them for support because I imagine that they will have more experience in this area. Finally, see about cross posting this to the RNY, Main and Insurance forums to see if you get input there.

Don't give up. This is just a bump in the road, not the end of the road.

Wishing you all the best,

Hi Judy - I agree with Barb - call CIGNA and ask them for specifics. I too had Cigna as my insurer and found the insurance forum here on OH to be a big help. I had letters from both my primary physician and my surgeon. You may want to place a call to your surgeon's office as well and speak with the insurance rep there - this is what they do for a living - good luck and God bless.

- Iris

I also have Cigna...I had to get a letter from my PCP stating all the diets I had tried, my medical issues, and a recommendation for the surgery...I also had to have a 6 month weight loss record followed by a physician...and they did the same thing with my denial letter about my BMI...I got a lawyer and with one letter from him, they approved me...his web address is:

http://obesitylaw.com

Also, the link for Cigna's bariatric policy is the following:

http://www.cigna.com/customer_care/healthcare_professional/c overage_positions/medical/mm_0051_coveragepositioncriteria_b ariatric_surgery.pdf

Hope this helps...Don't give up...they want you to...I fought with Cigna 4 years by myself...after one month with a lawyer, they caved...

Do you mind me asking how much your lawyer charged you?

hey judy - don't panic just yet. looks like you got some great advice already, but i jsut wanted to give you a heads up. i have cigna hmo as well and got denied at first and had to do a six month diet. but i was also given a care specialist through cigne who stepped me through the whole process. also, check with your surgeon. they may have a lot more information that you think. good luck and keep your chin up! its worth the wait to do it right!

You have already gotten some great advice.  My best advice is to APPEAL their decision.. make sure that you play their little game and do not give them a reason to say no.  I used to work in healthcare and insurance companies are the world's best at giving the runaround.  Just be diligent.  Good luck and keep us posted.  :)

Did I EVER have the same problem?!?  YES!  And I eventually got approval.  I started out with a different insurance company, had 2 failed approvals and switched to Cigna.  Then Cigna denied me a few times, a couple of lost appeals, and finally after threatening with an attorney ... yada, yada, yada ... and I never had to get an attorney, they approved it.  I went through torture and tons of hoops, but I had success by fighting.  Do NOT give up, especially if this is your first denial.  It's worth it.

Get them to spell it out for you, tell you exactly what they want, and then do it or prove that you've done it.  Get it in writing, take down all names you speak with.  And, speak with your surgeon's office and see if they are willing to help you out, too.  Mine was. 

Best wishes.  And my advice is FIGHT, FIGHT, FIGHT!