Cigna POS

This is an update to an earlier post I left, a Cigna supervisor instructed my surgeon's office to re-submit my claim to pre-determination. A week later (today) I made a follow up call and was told this was a mistake. They said that since I had been denied earlier in the process that now my claim has to be sent to appeals for an external review. One tactic to delay again, now I see from their web site I have to make a written request for this review, next they have 10 days to respond and then set up a date for the review, and then last the external review has 30 days to respond. I just can't believe this, I finally met my 6 months supervised diet, all of the evals have been done so why can't they review the claim instead of making me go thru this process. If anyone has an insight on what I can do please let me know.   Post Date: 9/11/06 7:00 pm I have a BMI of 74, 463 lbs, Asthma, High blood pressure, Severe knee & hip pain. Severe obstructive Sleep Apnea, currently on CPAP & Oxygen, Depression. I was denied 3 times back in the early summer because of no 6 month Doctor supv. diet. This was even after my Doctor talked to the Medical director who said he had no authority to overturn an appeal. My Doctor then sent in a letter to the appeal board. Their reason for denying No Medical necessity, no 6 month supv. diet, and no nutritional study (which they had). I was 4 months into the supv. diet at the time. I've now completed the 6 months supv. diet. The nurse at the Surgeons office contacted Cigna and got 3 different response from them. Finally a supv. told her to fax everything into the predetermination office with all of the notes. She sent in 37 pages of documentation to them which they confirmed today that they were recieved.  How do I proceed if I'm denied again? Bypass is a covered item on my PPO policy. I have a surgery date of 9/26 and I pray they don't deny me again. Thanks,  Tom

To me it would be a resubmit...you are not appealling their decision from earlier in the summer as if you had the 6 months then...you didn't. You have a completely new claim...now with the 6 months diet. I say call a 3rd time and see what you are told and go with best out of 3. Heck if anything resubmit anyway and see what happens as you start the appeal. To me the appeal would have be done at that point in time so unless you can show that at that point in time you had 6 months diet you don't have grounds to appeal their decision. They're on crack!

I wish you were right - I couldn't find anyone there with common sense. I'm now told my only choice is and external review.