Cigna Denial and Appeal

I have Cigna  and just received another letter  about my appeal.  I  called (10/20/06) and was told that they had  not received any additional info from my Doctor(cigna is requesting more info on my  6 month Dr. supervised diet).  Cigna  says requested services are not covered -  do not meet definition of med. nec. and adequate documentation of 6 mo diet. My BMI is over 50, multiple comorbidities including diabetes,, etc. I have their coverage statement  and my plan booklet  states it is  covered if medically necesssary.  Will my appeal rights be preserved if I have my Doctor make my initial coverage denial appeal?  This will be considered a first level appeal. I have asked my Doctor (endocrinologist) to do so. I was originally denied in 10/05 for  the diet .  Diet was done from 1/06 to 6/06 (consult 11/05 )and made sure I had appointments monthly as per guideline and also had nutritional consult  along with exercise etc. I feel Cigna is just deny  and deny again.   Any thoughts? Franni

Thanks for your reply Paul, I already have the coverage statement .It was the first thing I printed out over two years ago when I was researching wls.  They now also recognize BMI over 50.  As for the diet , my consult for the diet was 11/05  but could not get in office for the month of dec. so technically diet was from then.  Still needed six continuous weighins though.   Cigna is well aware of the number of my visits to the docs.  They have "lost"  or not received  paperwork from my surgeon, not paid for labs, etc.   I have received erroneous info from their service reps, so, I go by my benefit book. The " oh, that medical necessity",  and the EOB  is not correct or they don't pay for services, etc.    Cigna and I have had some issues.  I had already read your profile.   Glad you were approved  and all went well for you.   Those data sheets must have done the deed for you.  I have no problem with doing what Cigna wants  done for a benefit to be covered.  Just don't tell me that a fax was not received - repeatedly.That gets old fast. Yes you can send me any info you deem helpfull.  Thanks for your input, Franni

After being denied last year for my 6 mo not being documented correctly, I've just completed everything all over again and have submitted my info last week for approval. With that said, I wanted to suggest that you contact Cigna and ask for a Case Manager to go over all your paperwork and tell you exactly what is missing.  The Case Manager will work with you to get all the documentation together and in order for you.  This is how I found that the documentation was not done on mine last year.  The Case Manager will also give you a fax number and assist with making sure everything is complete.  If you are doing an appeal, make sure you submit your appeal all together.  I did start my appeal but my PCP's letter with to Cigna by mistake and Cigna took it as my second appeal.   I know it seems like all they are interested in is the paperwork and it's frustrating going thru this process with trying to dot every "i" and cross every "t" but it'll be worth it in the end.   One of the things I was told by my Case Manager is that the 6 mo supervised diet is done in 7 months as you need to have the initial consultation to be added to that.  So it's actually 7 weigh ins.  They do count full months.  I also did 6 months with a nutri twice.  She is backing everything I did for my supervised diet with my PCP.  You can never have enough documentation.   If you need help, feel free to email me. Good luck, Lorraine

Lorraine, Thank you for your reply.  I hope all goes well for you.  I will take your advise  on the call for a case worker to look everything over.  I am so confused right now.  What counts as to a nutritional consult? what counts as to exercise?  Behaviour modification?  Etc. ,etc.  It is all getting  run into the multiple letters.  My surgeons office has admitted they have very little experience with Cigna.  I feel abandoned by them.  But I will not give up.  Cigna is my insurer, they have been good to me.  I wish the whole process would be so much easier. In the last year I have read of so many denials with Cigna and Aetna. I hope to see more approvals - like one for you and me too.  I may be taking you up on that help.  I will be calling Cigna in the morn, hopefully I will get someone who can help. Thanks again, Franni

BINGO. Your "Surgeons office has little experience w/ Cigna". This is your problem, this is why you are now in appeals. Never trust a "trained insurance specialist" in a Bariatric Clinic. They sent in half baked paper work and now you're paying for it.  This has GOT to stop!  It's not just you. These places are getting so busy, your life is falling by the wayside.As many people have quoted here..."Their life is not affected either way"   I am so sorry.  What you have to do, is read your policy until you can recite it in front of 100 strangers verbatim. Then, you must understand it, and fullfill it's requirements sentence by sentence. And you have to do this yourself. These offices will make you THINK they know what they're doing, but they DO NOT.   It may seem overwhelming and like learning another language, but you can do it. 

Fed-up, You are so right!   I was originally given  the requirements for another health plan and told that was the same as mine.  Wrong !  I said that Cigna was not the same as that plan.  I still am not sure exactly what they sent in but I am requesting  from my insurer what was sent.  I am really considering  another surgery at this point if they will cover lapband.  I hope that others who are using the  surgeon's office are having better luck than I am.   I am overwhelmed but shall get thru this.  Good luck to you. Franni

Cign absolutely stinks, I've been denied 3 times and am now working on the external appeal. Make sure you document every one you talk to at Cigna. I have a BMI of 74 and numerous co-morbidties but I've been denied initially because of no documented 6 month diet which has been completed now the reason is no medical necessity even though I have letters from 3 Doctors saying that it is. My last chance is an external appeal which is in the process. Good luck, please let me know if you get approved.  

I'm sorry you are having to fight so hard for something that should have been approved for you.   1. Call and request a Case Manager to help you with processing everything you have.  They will go over the denial with you and explain exactly what is missing and what you need to get this approved.  2. Make sure you have all your paperwork and documents necessary that are required.  You should have a copy of everything that is being submitted.  Also, mail the paperwork via UPS, FedEx, etc. so that you have a receipt for delivery.   3) Make sure you document every phone call with names, dates, times and phone numbers to call them back.   While it is nice to have someone else submitting your paperwork for you, no one will look after your interests better than you.  So review everything prior to it being submitted. Lastly, this is not your last chance.  This will be your last chance with that submission but you can wait a year from the last denial and submit brand new.  Remember that the 6 mo supervised diet is good for 1 to 2 years, depending on the guidelines you have for Cigna.  So all is not lost for you.  Good luck and I'm on my 2nd appeal. Lorraine

I have a file 2" thick with documentation  and Cigna still says not medically not necessary. My BMI is 74, high blood pressure, severe knee and joint pain, asthma, bronchitis, cardiac pain, and severe abstructive sleep apnea (doctors words not mine). His comment was I amazied you haven't died in your sleep. Attorney has all of the documentation along with my money so I'll let him fight the external appeal. Cigna hopes you'll go away or die so they don't have to pay.