Cigna PPO denial.....help please

I was recently denied approval for RYN based upon the following; Complete documentation of a 6 month physician-directed weight management program in the past 1 of 2 years without significant gaps. The thing is that at my doctors suggestion I started Weigh****chers and kept a daily log. I submitted this to the surgeon and his clinic but somewhere along the line the Ins co says a weigh****chers log is not adequate for their criteria. My Current stats are: Weight: 388 Height: 5'10" BMI: 55.6 Co-Morbidities: Sleep-apnea, depression, weight bearing joint pain, lower back pain, extreme likihood of diabetes, hypothyroidism, insomnia, high blood pressure and asthma. My daily activities consists of a vigorous 30 min walk with my dogs, daily house work, and weekly yard work. Along with trying to keep up with my 6 yo daughter. Finally the question: Has anyone ever gotten approval with a weigh****chers plan, and if so does any one have any suggestions on how to compose an appeal letter that expresses the changes that I have made and the changes that are to come? Also if anyone has a good example of an appeal letter please forward those as well as any advice to me at [email protected]. Thanks all in advance Jeff in Tennessee

Hi Jeff, Sorry to hear about you denial. I have Cigna PPO and was approved after the 1st try. I used some of my weigh****chers info when I sent in my packet but I also did the 6 month diet and believe that's what got me approved. I know the waiting sucks but it might be to your benefit to follow their guideline and do the 6 month diet as I've heard so many get denied for not doing it. I know I did alot of research on this site and the yahoo site (cignasqueakywheels). They had some appeal letters posted there that you might want to check out. Anyway, good luck to you and please consider the 6 month. From the looks of it it sounds like that's all you need to get approval so it might be worth it instead of going through the appeals process which could take longer. Just my .02. Good luck!

Personally I think your chances are zero. It is pretty clear that it has to be a medically supervised diet. Typically this would mean going to a registered dietician that your doctor would refer you to. The doctor should note your beginning weight in his medical records and the reason for sending you (co-morbidities) and then again when you are done noting your progress. Would also help to go in about once a month or at least every other month to the doctor as well. For my two cents, get started on this now as you will spend a lot of time an energy trying to get this approved and you could be half way there. Believe me, I know this sucks. Jim Randall

Hi, Just wanted to let you know if you look under insurance on this site it has an example of an appeal letter. I also am going through an appeal waiting for approval i have Aetna POS II . All the insurance companies are a pain. They make it so difficult when you are trying to make a big life change. This is what I keep telling myself God did not bring me this for to leave me. ....God Bless.

Hi Jeff, I know how frustrating this is trying to get the surgery that will save your life and help you live! I too am trying to get there with nothing but obstacles in the way. I sometimes just say screw it and think, "Might as well give up because I am too tired and sick to fight and the insurance companies KNOW this." BUT, I do want to live as do you and so fight we must! (Gag, spit, choke, PUKE!) You might want to try and contact Gary Viscio. He is a bariatric attorney and can often times find ways to get things approved: [email protected] I would also suggest that you try to get on disability through social security. They are covering this surgery because they understand the necessity of it and the FACT that it takes people OFF of disability and helps them get back into life....or INTO life for the first time for people like me. Please don't give up. You are worth it and deserve to have this surgery as we all do. I will pray for you..... HANG IN.... Judy

Go ahead and do the 6 CONSECUTIVE month appointments with your PCP..my surgeon's office gave me a log to keep the info on.. the 6 mo will TOTALLY breeze by......... this is what got me approved thru Cigna in 24 hrs. I had a Weigh****chers log but it had nothing to do with my approval. The 6 mo diet must be MEDICALLY supervised. Have your ducks in a row and all will be fine. Use the next 6 mo to lose a little weight and change eating habits as well as getting your mind together. Good luck Jeff!

Cigna wants the 6 mo supervised diet and it has to be consecutive 6 mo with one month additional as the consultation. You can have your PCP have you do weigh****chers but you will have to do "ALL" your weigh ins and vitals with your PCP. Trust me, I already made that mistake the first go around and this is my 2nd 6 mo supervised diet. What's happening here is that they want to make sure you are educated on WLS and that you have exhausted all attempts at losing weight. With the PCP documenting this, it shows you have been compliant with your diet and exercise program and still have trouble with weight loss. Six months will go by faster then you'll know. Beats having to do a 12 month one that some insurance companies are requiring. Good luck and get motivated on the 2nd attempt. It's worth it. Lorraine

Hi Jeff.  I have Cigna PPo out of Florida.  It has been 3 years since my surgery but I was turned down twice and then finally approved.  I did weigh****chers and they accepted it.  I gave them my little weigh in book.  Also I had been going to my doctor and she was keeping track of my weight.  That only had to be everry two months I believe it was.  I gained weight while on WW and I still got approved.   Here is a copy of my letter to Cigna...

March 3, 2003

 

 

 

CIGNA PPO

 

 

Re:     

 

 

Request for Pre-approval for Gastric Bypass (CPT-4 Code = 43847)

 

 

Note: (I meet both Milliman and Robertson and U.S. Federal Guidelines)

 

 

1.                  Milliman and Robertson Guidelines for the Gastric Surgery for Clinically Severe Obesity 15 CPT-4: 43847

and

2.                  U.S. Federal Clinical Practice Guidelines for the Treatment of Obesity set down in National Institutes of Health Consensus Conference. Released June 17, 1998, the Federal guidelines on obesity were by the National Heart, Lung, and Blood Institute (NHLBI), in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)).

 

Dear Sir:

 

I am writing to request your pre-approval for gastric bypass surgery (Diagnosis Code 278.01 Procedure Code 43847).  I am 4 ft 10 ½ inches tall and I weigh 318 pounds. My body mass index is 62. The body mass index is calculated by dividing a person's weight in kilograms by their height in meters squared. When a man's BMI is over 27.8, or woman's exceeds 27.3, that person is considered obese. The degree of obesity associated with a particular BMI ranges from mild obesity at a BMI near 27, moderate obesity at a BMI between 27 - 30, severe obesity at 30 - 35, to very severe obesity for patients with a BMI of 40 or greater ^[1],^[2],^[3]. Therefore, I am classified as being very severely obese. The annual number of deaths in attributable to obesity has been estimated to be 300,000 deaths per year. ^[4],^[5] With my abnormally high BMI, I am at an increased risk of death at my present weight.

 

I ask for your pre-approval for this surgery. I will detail the issues of medical necessity.

 

I am having significant adverse symptoms from my obesity. I have difficulty standing, and in doing any kind of exercise, even walking more than a short distance. I have difficulty performing any daily activities, and in participating with my family in recreational activities.

 

I have sleep disturbances and the weight loss would help with sleep disturbances and prevention of sleep apnea.

 

I am not diabetic. However I run the risk of adult onset diabetes from obesity.  In addition to being a morbid and lethal disease, diabetes has been shown to be very expensive to treat. Rubin et. al. in a study in 1992 showed that yearly health care expenditures for confirmed diabetics ($11,157) were more than four times greater than for nondiabetics. In 1992, diabetics constituted 4.5% of the population but accounted for 14.6% of total health care expenditures ($105 billion). Confirmed diabetics constituted 3.1% of the population but accounted for 11.9% of total health care expenditures ($85 billion). Health care expenditures for people with diabetes constituted about one in seven health care dollars spent in 1992. (Diabetes in America, 2nd Edition, The National Institutes of Diabetes and Digestive and Kidney Diseases, 1995, NIH publication number 95-1468.) Health care insurers should take note of these findings. Gastric Bypass has been shown to cure diabetes and thus it is cost effective for insurers to pay for surgery to cure diabetes and prevent its complications. Nearly 80 percent of patients with NIDDM are obese.

 

I also suffer from high blood pressure. Essential hypertension, the progressive elevation of blood pressure, is much more common in obese persons, and leads to development of heart disease, and damage to the blood vessels throughout the body, causing susceptibility to strokes, kidney damage, and hardening of the arteries. If hypertension is not under control, many complications can occur as a direct result of continued high blood pressure. 60% of hypertensive people are obese. The weight loss attained by gastric bypass surgery will cure hypertension.

 

Also, I have high cholesterol. When there is too much cholesterol in your blood, the excess can become trapped in the walls of your arteries. By building up there, the cholesterol helps to cause hardening of the arteries or atherosclerosis. And atherosclerosis causes most heart attacks. How? The cholesterol buildup narrows the arteries that supply blood to the heart, slowing or even blocking the flow of blood to the heart. So, the heart gets less oxygen than it needs. This weakens the heart muscle, and chest pain (angina) may occur. If a blood clot forms in the narrowed artery, a heart attack (myocardial infarction) or even death can result.

 

Arthritis is a major comorbid condition that I have. One of the nearly intolerable problems is the constant pain of the weight-bearing joints. An increase in body weight adds trauma to weight bearing joints and excess body weight is a major predictor of osteoarthritis. This is a mechanical problem and not a metabolic one. The hips, knees, ankles and feet have to bear most of the weight of the body. These joints tend to wear out more quickly, or to develop degenerative arthritis much earlier and more frequently, than in the normal-weighted person. Eventually, joint replacement surgery may be needed, to relieve the severe pain. Unfortunately, the obese person faces a disadvantage there too -- joint replacement has much poorer results in the obese. Many orthopedic surgeons refuse to perform the surgery in severely overweight patients. The permanent weight loss of gastric bypass surgery will markedly decrease problems with arthritis and the ever-increasing expenses to the insurance companies that will surely follow.

 

I suffer from venous stasis disease. The veins of the lower legs carry blood back to the heart, and they are equipped with an elaborate system of delicate one-way valves, to allow them to carry blood "uphill". The pressure of a large abdomen may increase the load on these valves, eventually causing damage or destruction. The blood pressure in the lower legs then increases, causing swelling, thickening of the skin, and sometimes ulceration of the skin. Weight loss after gastric bypass can relieve venous stasis disease.

 

I am at risk for hypercholesterolemia (high cholesterol). When there is too much cholesterol in your blood, the excess can become trapped in the walls of your arteries. By building up there, the cholesterol helps to cause hardening of the arteries or atherosclerosis. And atherosclerosis causes most heart attacks. How? The cholesterol buildup narrows the arteries that supply blood to the heart, slowing or even blocking the flow of blood to the heart. So, the heart gets less oxygen than it needs. This weakens the heart muscle, and chest pain (angina) may occur. If a blood clot forms in the narrowed artery, a heart attack (myocardial infarction) or even death can result.

 

Because of my weight, I am depressed. Seriously overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, sneers and remarks from strangers. They often experience discrimination at work, and cannot enjoy theatre seats, or a ride in a bus or airliner. There is no wonder, that anxiety and depression might accompany years of suffering from the effects of a genetic condition -- one which skinny people all believe should be controlled easily by will power.

Coronary artery disease is another problem caused by clinically severe obesity. Severely obese persons are approximately 6 times as likely to develop heart disease as those who are normal-weighted. Coronary disease is pre-disposed by increased levels of blood fats, and the metabolic effects of obesity. Increased load on the heart leads to early development of congestive heart failure. Severely obese persons are 40 times as likely to suffer sudden death, in many cases due to cardiac rhythm disturbances.

 

I become short of breath on any exertion. I cannot climb even one flight of stairs without stopping, and have a very difficult time performing the ordinary day-to-day duties of living, such as shopping, cleaning, getting in and out of a car or even getting in and out of chairs.   I was once physically active and enjoying gardening, but at this time, I find that I am unable to perform any recreational activity, and feel depressed because I cannot control or lose the weight. Climbing stairs or even walking short distances causes the obese to become very short of breath. Obese persons find that exercise causes them to be out of breath very quickly. The lungs are decreased in size, and the chest wall is very heavy and difficult to lift. At the same time, the demand for oxygen is greater, with any physical activity. This condition prevents normal physical activities and exercise, often interferes with usual daily activities, such as shopping, yard-work or stair climbing, and can be completely disabling. Losing weight will cure respiratory problems.

 

I have made many attempts to lose weight, including: Weigh****chersJenny CraigNutraSystemAtkins dietNutritionist consultsHypnotismGym membershipsRichard SimmonsOvereaters Anonymous

¼¼¼¼and many of the over-the-counter diet plans and diet medications.

 

I have included exercise with all weight-loss attempts. I can lose some weight, but then I gain it all back and more. There is not one study that shows that dieting brings permanent weight loss. The National Institutes of Health, in 1991 and 1992 consensus statements, rebutted conventional diets for morbid obesity, and pointed to this important fact: Diets alone cannot be successful for the morbidly obese.

 

Obesity has been shown to directly increase health care costs. In an article in the March 9, 1998, issue of the Archives of Internal Medicine 17,118 members of the Kaiser Permenente Medical Care Program were studied to determine the association between body fatness and health care costs. The results showed that patients with BMIs greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients with BMIs under 30. For patients with BMIs greater than 30, the study also showed increases in health care costs related to diabetes and hypertension.

 

Americans spend an additional $33 billion dollars annually on weight-reduction products and services, including diet foods, products, and programs. Most of these expenditures, as is evidenced in my case, are not effective. Rather it can expected that I will continue to gain weight over the ensuing years and add to this present list of obesity associated illnesses.

 

Seriously obese persons suffer inability to qualify for many types of employment, and discrimination in employment opportunities, as well. They tend to have higher rates of unemployment, and a lower socioeconomic status. Ignorant persons often make rude and disparaging comments, and there is a general societal belief that obesity is a consequence of a lack of self-discipline, or moral weakness. Many severely obese persons find it preferable to avoid social interactions or public places, choosing to limit their own freedom, rather than suffer embarrassment.

 

I do not want the surgery just so I can look great. I need it for health reasons, as you can see. I ask that you pre-approve this surgery so that I can become a healthy, productive person once again. Thank you very much for your consideration.

 

Sincerely,

 

 

 

 

---

^[1] Weighing the Options: Criteria for Evaluating Weight-Management Programs. Institute of Medicine , National Academy of Sciences. 1995; 50-51.

 

^[2]Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell , S.M. Increasing prevalence of overweight among US adults. Journal of the American Medical Associatio*****; 272:205-211.

 

^[3]Troiano, R.P., Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Overweight prevalence and trends for children and adolescents: The National Health and Nutrition Examination Surveys, 1963 to 1991. Archives of Pediatrics and Adolescent Medicine,1995; 149:1085-1091.

 

^[4]Daily dietary fat and total food-energy intakes: Third National Health and Nutrition Examination Survey, Phase I, 1988-1991. MMWR Morbidity and Mortality Weekly Report. 1994; 43:116-117, 123-125.

 

^[5]Weight control: What works and why. Medical Essay. Mayo Foundation for Medical Education and Research, 1994.