Denied!

To whom it may concern: Tonight my wife received her 2nd denial letter from Cigna for the Adjustable Gastric Bypass surgery, and tonight is one of the worst nights we've had since this whole process began. We have so many questions, so many frustrations, and we feel like lashing out at everyone involved. For the first time since we began this grueling process, we actually think we're going to fail - we've encountered yet another dead end road. Oh, I'm sure we'll find the strength to keep fighting, but Cigna's resolve to reject our appeals seems unwavering. After the 1st denial, the denial letter stated that there was no documented 6-month duration of a doctor-assisted weight loss program. We found that odd, since Karen had been working with her physician for over a year to find a way to lose weight. Throughout this process, she attended weight loss support groups, weigh****chers, Atkins, Xenical, Meridia, and increased exercise (which ended up causing joint pain in her knees). So we called the Lisas at Dr. Patterson's office to find out if these doctors visits were in the records that were sent to Cigna, and we found out that they were NOT included! This was a shock to us, since this information was so very vital to making our case. In one respect, we were relieved, because we thought that this was the missing information Cigna needed to approve our request. We were also very frustrated with ourselves and Dr. Patterson's office for letting this major oversight to occur in the first place. So we spent a week preparing our appeal, including the omitted records, and a very well-written appeal letter. Within a week, we received word that Cigna had denied us again, this time "due to lack of proper follow up". Today we received the denial letter, and it was extremely extensive and detailed. They require a recent six month doctor assisted weight loss program with monthly doctors visits (previously, Karen had seen her doctor about every 3-4 months). They also stated that they require a psychological evaluation to evaluate why Karen cannot successfully lose weight. However, we already saw (and paid for, out of pocket) a psycologist, Dr. Ude, as part of Dr. Patterson's pre-surgery program. Karen also had a sleep study, saw a dietician, had blood tests, etc etc. Now we're wishing we knew then what we know now about Cigna's policy. What's so incredibly frustrating about this is that MONTHS and MONTHS ago, when all this started, we called Cigna to ask what their requirements are for bariatric surgery, and they told us that they could only tell Karen's doctor what the requirements are. We were then informed that the Dr.. Patterson's Health Plan Office was there for that reason. We've tried so hard to work with Dr. Patterson's office to get this information, and we have had nothing but frustrations working with them. Many times our calls are not returned, or are returned after several days have past, and they provided very little assistance in our denial letter. We are wondering why these simple steps didn't take place by Dr. Patterson's office: - Contact our insurance company to find out the requirements they have for approving this procedure - Review the records to be sent the insurance company to identify possible oversights or missing requirements We tried doing this ourselves, but Cigna was not forthcoming with the information, and we assumed that Dr. Patterson's office would take care of this for us. This is why we want to lash out at everyone who has been involved. We feel as though there has been not enough attention to detail, not enough professionalism, and not enough support from Dr. Patterson's office. There's nothing worse than getting your mind in the mindset that "I'm gonna do this - I'm ready - I'm ready to take this next step" only to end up, months later, on a tuna and cottage cheese diet, with 2 denial letters, and several unreturned phone calls. I'm writing this letter tonight because Karen is at the end of her rope. Where do we go from here? Its so hard to read other people's testimonials about how "Cigna through Intel" approved their request, and now they've lost so much weight, and they are so much happier. Reading this used to give us hope, inspiration, determination, and motivation. Now it makes us pound our fists on the table and wonder why... Sincerely, David Henkemeyer

Dear David & wife, Don't despair just yet......I cannot account for anyone else's actions but what I do know is what I did. This is how I got my Insurance information. I looked at my husbands employee handbook that has our medical policy in it. It states very clearly that "Bariatric surgery to correct morbid obesity" was a covered plan. So I was happy to hear that and called and asked then on the phone is this all true. They then mailed me a MORE DETAILED description of my benefits. This is YOUR Insurance and you have a right to know what your specific plan covers. If you cannot get through you need to talk to your HR person at work who set's up your Insurance for employees and ask her/him to call on your behalf to get the info you need. Regarding the doctors offices they have been very good working with me, but they also require all these tests to be done prior to surgery which I also disagree but am following it with the exception of the Pscyh eval. I am taking that after I'm approved. Dr. Patterson they told me would not except that, but maybe Dr. Hong would so I am going with him for now. There is also the appeal lawyer everyone talks about Walter Lindstrom, as a last resort you may want to give him a call. Apparently he has gotten approvals after others have not had any luck..... I wish you both the best of luck...hang in there and be persistant....that's what I am doing. Even if it takes a YEAR! Nadine

Hello David & Karen, I went thru 2 denials of Blue Cross BlueShield of Illinois before finally being approved for laproscopic roux n y. I didn't even try for the lap-band (which would have been my preference) because this division of BCBS has not approved one yet. What finally had to happen to get approval was re-send ALL of the notes, labs, specialists' results PLUS a year of chart notes from my Primary Care Physician's records of weight and everything else I'd seen him for in that time period. WITHOUT THE HELP AND SUPPORT OF MY PRIMARY CARE PHYSICIAN THE APPROVAL NEVER WOULD HAVE HAPPENED! I'd suggest talking to your wife's PCP and explain the roadblocks you're hitting and see what the doc says and is willing to do to help get approval. I found that contact on a regular basis with Cammie helped a lot too. She is the referral co-ordinator for not only Dr Patterson but all of the Oregon Clinic.. so often she would take up to 3 days to return calls. After submitting new information, I would wait 4-5 weeks before calling Cammie again for updates. It takes the insurance companies that long to evaluate information. ( what a crock..don't get me started on that!) Another MAJOR frustration on my part was the insurance company. No place in the policy book we have available, does it mention gastric bypass surgery.. approved or denied. I had to call BCBS 5 times before someone would return my call and give me requirements. After the first refusal, I called and asked again what the requirements were. This time they said that Jenny Craig, Weigh****chers, Nutri-Systems etc weren't allowed as "time" for weight loss because it "wasn't under doctor supervised care". In defense of Dr Patterson's staff, the two Lisa's really aren't involved in the insurance part of the approval system. They make sure all of Dr Patterson's required tests/labs are turned into their office. EVERY insurance company is different and has different requirements. It would be impossible to know all the details of each policy. However, I do sympathize with your frustration and resentment. Call in the help of the HR director in dealing with the insurance company. I wanted to keep the surgery "quiet" at my work place, but if there had been another denial.. I would have brought in the HR Director and his big guns to fight on my behalf. Please don't give up. My first consultation with Dr Patterson was October 2, 2003 I finally got approval March 20, 2004 and my surgery was April 12, 2004. Stay with it. Contact Cammie and asked that she re-submit ALL of Karen's results/forms/ labs at one time. It WILL happen! Penny