CIGNA

Hi, I have Cigna open access plus.Originally denied 10/05 for med. nec. and 6 mo diet. Did diet with my Dr.  Took diabetes ed class with nutritional consult , diet exercise etc. Had psych and initial nutri conslt with surgeon.  My endo is my Dr. so that was covered.  My BMI was originally  56 now is 52.7.  I am diabetic, high bp,edema,hyperlip,etc.  Policy will cover for med. nec. I am going to have my Dr. do my initial appeal.   This is a first level appeal.  He recommended the surgeon and the type of surgery to me as he is my treating physician. Surgeons office lost my file so I had to put that back together.  Cigna keeps saying they need more info.  I know they will cover as another employee has had the surgery(RNY).  My plan is out of NY state which from Gary's info  looks good.  Cigna told me they did not have info from surgeon and I know it was sent.  A Cigna nurse called and told me what they needed and I asked for that info to be sent to them.  I am now  on appeal with Cigna's Dr. decision. All I can say is that I think Cigna sends denial letters automatically  and the service reps are not helpful, once you get thru voice mail he**. Franni

I have Cigna Open Access Plus and started this journey 7/05.  After doing, what I thought, was a 6 mo supervised diet, I was denied twice.  I was told I could resubmit for pre certification by just starting over, which I did and just finished.  After calling and talking to Cigna yesterday, I will have to submit everything as a 2nd level appeal because you cannot resubmit until 12 months have passed from the denial (02/06).   So I requested a Case Manager from Cigna to assist me with the approval process.  My surgeon's office has not submitted the paperwork yet and will be done by the beginning of next week.   At present I have done 7 mo of the 6 mo supervised diet, which I included 6 nutri visits, 2 psych evaluations, 15 months of support group meetings, bmi 46.7, now have hypertension (which I didn't have before) and letters from everyone involved. My denial was because of the 6 mo supervised diet.  I'm hoping that having the Case Manager assisting will make things run a little smoother.  I do know this is stressing the heck out of me.   I will admit that I'm glad I've had this time to continue to educate myself regarding WLS and it has only reinforced my decision to do this.

Cigna has decided to uphold original decision denial for my RNY.  Cigna has added this to my denial : Medically necessary covered services and supplies are those determined by the medical director to be:
*required to diagnose or treat an illness,injury,disease,or its symptoms:
*in accordance with generally accepted standards of medical practice:
*clinically appropriate in terms of type,frequency,extent,site, and duration:
*not primarily for the convenience of the patient,Physician or other health care provider: and
*rendered in the least intensive setting that is appropriate for the delivery of the services and supplies. Where applicable, the Medical Director may compare the cost effectiveness of alternative services,settings or supplies when determining least intensive setting.   Does this mean Cigna  wants a different surgeon, surgery, and or hospital/facility?

I did notice that Cigna has recently added  Cigna Certified Bariatric facilitys for surgery .  Atlantic City(Dr. Openchenkco)  and pittsburgh for pa.   Does Cigna want Surgery done only at their approved facilities?  I am now going for an external review .   I will be busy gathering my file from dr. and surgeon and print up informational studies.  I think my chances are good.  I think I will call and ask Cigna about their choice.  I could change  my surgeon if that would help them cover my surgery. Franni