What do I need to do?

I have CIGNA/HAP preferred HMO, but in actuality my employer self-insures and CIGNA administers. My actual policy says NOTHING about a 6-month medically monitored diet; I found out about it when researching. I don't have a 6-month diet, because my PCP isn't affiliated with a facility that offers one; so she always referred me to weigh****chers or something similar. Of course the medically monitored diet isn't covered by insurance, and to start one now, would cost me about $3,000 over the next 6 months. I don't want to pay $3k for yet another diet that won't work! My actual policy says only "treatment of clinically severe obesity, as defined by the body mass index (BMI) classifications of the National Heart, Lung, and Blood Institute (NHLBI) guideline is covered only at approved centers if the services are demonstrated, through existing peer-reviewed, evidence-based, scientific literature and scientifically based guidelines, to be safe and effective for treatment of the condition. Clinically severe obesity is defined by the NHLBI as a BMI of 40 or greater without comorbidities, or 35-39 with comorbidities." It goes on to specifically exclude subsequent plastic surgery, as well as "weight loss programs or treatments, whether prescribed or recommended by a Phystician or under medical supervision". I know I'm grasping at straws, but do you think if I point out that my actual policy doesn't require a 6-month program, and CIGNA's bariatric surgery coverage guidelines says that the policy can override the guidelines, AND point out that it's a private insurance policy governed by the specific wording of the policy, rather than a standard CIGNA policy, that I'll have a leg to stand on? Any advice would be appreciated. Thanks, Erynn

This is something best asked of your insurance. It is important that you get a compitent person to explain it to you, if they hesitate and try to get you off the phone......call back and get someone who is able to take the time to look for what you need. Find out who makes the decisions and get thier # if you can. Like if  you need pre-certification, find out pre-certification dept #. call every day if you have to.... it is worth it. My policy didn't say that I had to meet certain criteria in and of itself...... but you have to delve deeper... if cigna has a medical policy about weight loss surgery, whether it is in your policy or not... you have to meet it. I would try to find the cheapest way to go about getting medicaly monitered dieting if I could.   I had to see a nutritionalist, and it wasn't a covered service, but it was worth it for me!good luck!

I can personally tell you that Cigna will not budge on the 6 month requirement. I was denied initially because of it and even at the 4 month mark of the diet they refused to budge even when my PCP did the peer to peer review. At this point of the year they have been horrible claiming to have never gotten paper work and not even returning calls. I'm still fighting and maybe I will win on external appeal. Do everything you can to make sure that your Doctor can prove it is medically necessary. If they can treat you with Meds for co-morbidities then they will and deny you because of not medically necessary. My opinion hire an attorney. Cigna has already dropped bariatric surgery in 4 states and is hoping to do more next year. I pray every night that I get some help and hope you do also. Tom

quote: If they can treat you with Meds for co-morbidities then they will and deny you because of not medically necessary. With her BMI being 40 or above, co-morbs don't even need to exist.... the BMI alone is the medical necessity.

My BMI is 74, high blood pressure, severe knee and joint paint, asthma, stress incontinence,  sever obstructive sleep apnea ( on Cpap & Oxygen) ,  depression, etc . and I'm still told not medically necessary. Now tell me why Cigna would say not medically necessary.

I read a lot about the cost of the medically monitored diet etc, but I'm not sure why... I also had a 6 month diet requirement and I satisfied it easily without much hardship.  I met with my PCP in Feb and told him I wanted a gastric bypass.  We began the research and the surgeon's program the next month.  I found out immediately that I needed the 6 month diet.  So my PCP put me on one and I went back to him each month.  Each month I had a dr's appt and we discussed nothing but my weight.  These were very brief appts.  I'd get weighed.  We'd talk and he'd document.  After six months of this, he sent the records into my insurance company along with a letter stating why medical intervention was no longer the standard of care for me and that was that.  I was approved in about 2 1/2 weeks.    It cost me the office visit co-pay and was really no big deal at all.