This article in AZ Rep newspaper

Insurers saying no to bariatric surgery requests Republic file photo Kiara Mitchell and her sons Matthew and Ryan show off a her 185- pound weight loss after gastric bypass surgery. Many patients love the results but not the bill - insurance rarely covers the surgery. Jodie Snyder The Arizona Republic Oct. 2, 2003 12:00 AM Buoyed by the success of patients ranging from Al Roker to J.D Hayworth, many people are turning to bariatric surgery, including gastric bypass, for help with their life-threatening health problems. But as demand soars, some insurers are requiring more information, including proof that people have gone through 26 weeks of medically supervised dieting. "Almost everyone gets denied their first time," said Kiara Mitchell, who runs an online support group for Valley residents who are interested in or have gone through weight-loss surgery. "They are getting very, very strict. Who knows what they are going to do the next year," she said. That strictness is understandable. The surgery costs around $25,000. With post-surgical care, including ongoing education about diet and exercise, the total bill can reach $100,000. Yet, other patients say insurers approved their requests for the surgery within days. It all depends on a patient's need, proof of that need and the rules of their insurers and employers, health care providers and patients say. The number of Americans turning to weight-loss surgery has gone from 40,000 in 2001 to an expected 103,000 in 2003, according to the American Society for Bariatric Surgery, a professional association for weight-loss surgeons. And it is unlikely demand will slow. It is estimated 25 percent of the U.S. population is obese. Valley health officials say as many as 100,000 people in the area, about the population Yuma, could qualify for the surgery. At least four bariatric centers have opened in the Valley in the past two years. Banner Mesa Medical Center is planning to open one in the first quarter of 2004. "We think there is great demand for it in the community, especially in the southeast Valley," said Venus Gaines, manager of bariatric services at Banner Mesa. "This is a business, and if there is demand, then there will be more programs," said John Truscott, spokesman for Forest Health Services, a Michigan-based company that operates nine centers across the United States. It opened a center in Scottsdale earlier this year. As interest grows, so have insurers' questions, said Sonja Nelson, director of bariatric services at Banner Good Samaritan Medical Center, one of the Valley's more established centers. Recently, the center did nine surgeries in one day and it has a three- to six- month waiting list. "Five to seven years ago, the insurers said, 'No way.' Then it was, 'Let us put it through medical review,' " she said. "Now there has been an explosion in requests, and insurers are saying, 'Wait a minute,' " said Nelson, who estimates that 90 percent of the center's patients are covered by insurance. Walt Lindstrom Jr., an attorney with the Center for Obesity Law and Advocacy in San Diego, agrees. "There are a lot more programs out there and there are a lot more patients out there and . . . you are seeing a lot more denials," he said. Lindstrom estimates he has 100 or more active cases from across the country, several of them from Arizona. In particular, he is receiving calls from CIGNA HealthCare of Arizona enrollees who are routinely denied. A typical patient may have diabetes, a high body-mass index and sleep apnea, but the person's doctor didn't record previous diet attempts. CIGNA requires proof that a patient was on a 26-week diet. FYI ? Gastric journey ? J.D. Hayworth sheds pounds, regains fitness ? Surgery answer to trio's obesity ? Gastric surgery helps many, not all ? J.D.Hayworth has surgery to lose weight ? Obesity researchers find hormone infusion that makes people eat less ? Gastric surgery for severe obesity ? NBC weatherman Roker's weight-loss secret: Gastric bypass ? Loss of weight is Cardinals coach's gain Insurance hot buttons Some of the most common subjects of HMO disputes: ? Gastric bypass. ? Breast alteration. ? Varicose vein removal. ? MRIs. ? Foot orthotics. ? Speech/physical therapy. ? Infertility treatments. Source: Harvard/Rand study in the "Journal of the American Medical Association" CIGNA officials said that like other insurers, they are receiving more requests for the surgery, but have no specific numbers. CIGNA says it is consistent with federal guidelines when it comes to asking for people to be on diets 26 weeks before getting the surgery. Health care coverage varies by employer. Some employers cover bariatric surgery while others exclude it, Anderson said in a written statement. In general, insurers are concerned that the right people get the surgery, said Cheryl Randolph, spokeswoman for PacifiCare. "This is a relatively new procedure. It is not for everyone," she said. In general, bariatric facilities will only take patients who are at least 100 pounds overweight or who have a body-mass index rating of 35 with certain health conditions. Other factors, such as higher body-mass index, also may be a factor. Adding to the complication is what insurers will cover. Gaines of Banner Mesa believes insurers increasingly will cover the surgery, but not necessarily all the follow-up services. Those services are critical to the patient's success, she said. Valley bariatric programs report that only 10 to 25 percent of their patients pay their own bills. "Sometimes they have to borrow money," said Bill Blackstone, officer manager of Scottsdale Bariatric Center. "But they feel that it worth because of the health issues."

UH HUH, read it, and then a I gave her the REAL story...(I e-mailed her as did a few others from our other message board) she states: CIGNA says it is consistent with federal guidelines when it comes to asking for people to be on diets 26 weeks before getting the surgery. YYYYAAAH, OK, so I did that. I completed my 26 weeks as of Sept. 15th and was shot down a THIRD time. YAH, THEY'RE consistent my BUTT! Everytime I completed what they said to do, they'd change the criteria, or make up a NEW (BOGUS) ones. I really don't even know WHY I was denied, as she never bothered to call me back. Simply left me a voicemail saying DENIED, no mention again of why, though when I talked to Diana in CA Cigna Nat'l Appeals a week ago, she was questioning me due to a lack of FOOD LOGS. Now they are requesting food logs!! WHAT THE......?? Imagine that!! Now, they don't require that for EIGH****CHER clients!! So, I'm off to write yet ANOTHER appeal letter. This is IT. MY final chance with an external review board. I'm not holding my breath.