Cigna grrrrrrrrrrrr

Yesterday I called my insurance (Cigna POS) because I needed to know what I need for my consultation with Dr Roslin in November for a BPD/DS.  They told me I need a referral from my PCP no problem. Then they directed me to a document to bring to the surgeon when I have my consult telling the requirements to be deemed medically neccesary.  On the first page of the document I saw this

Bariatric Surgery Procedures:

When the specific medical necessity criteria noted above for bariatric surgery have been met,

CIGNA HealthCare covers ANY of the following bariatric surgery procedures:

• vertical banded gastroplasty

• Roux-en-Y gastric bypass

• adjustable silicone gastric banding (e.g., LAP-BAND®)

CIGNA HealthCare covers adjustment of a silicone gastric banding as medically necessary to

control the rate of weight loss and/or treat symptoms secondary to gastric restriction following a

medically necessary adjustable silicone gastric banding procedure.

CIGNA HealthCare does not cover the following bariatric surgery procedures, because they are

considered experimental, investigational or unproven (this list may not be all-inclusive):

• biliopancreatic diversion with duodenal switch (BPD/DS)

• Fobi-Pouch (limiting proximal gastric pouch)

• intragastric balloon

• mini-gastric bypass

• sleeve gastrectomy (SG) The guy on the phone said there is no way to appeal that kind of denial.  What do I do now? I'm not going to settle for any other type of surgery, its the DS or nothing, this is the only choice for me due to other medical problems that require me to take NSAIDS on an almost daily basis. I can't change my insurance coverage, Cigna is the only kind offered at my job. I spent an hour yesterday crying about this because I feel so helpless.

I hate to say this but he is probably right.  Those procedures are still considered investigational, although many have had it done, they still don't have the stats, or years that other procedures do.   What about the Lap-band?  I thought you could still take NSAIDS with that.  Will you still have the problem after losing weight that you take them for?  What about injections?  If you could get injections the RNY might work.  I know where you are coming from I am worried, I take 800mg Ibuprofen every day at least once.  After I have my surgery I won't be able to take it.  But I have seen posts on here where a person said that 1 extra strength tylenol now works for them where before it didn't.   I am counting on my weight loss to relieve my pain in my back, hips, & knees.   I just got a denial letter from Cigna for the RNY, luckily I have Blue Cross primary & they approved it.  Amazing that 2 different insurances can get the same info and 1 deny & 1 approve isn't it?  I think they need to set a standard for the entire insurance industry to follow.   What about Mexico?  Could you afford to pay for it?  I would go to the DS board and post there too.. Sorry I wasn't much help. Kerri

My BMI is too high to be eligible for a lap band.  The DS is not a new surgery, it has been around as long as the RNY and has been proven much more effective in the long term for SMO folks like me.  Plus the fact that what I take NSAIDs for has nothing to do with my weight, my jaw is completely messed up and I have constant headaches because of it.  I am allergic to most narcotic pain meds, so to cut NSAIDs out of my regimen entirely would be very difficult.  My pain has to do with inflammation and a slipped disc in my jaw joint, and tylenol unfortuneately has no effect on it whatsoever.  DS is truly my only option. I have done tons and tons of research on it, and it is the only choice for me.  Thanks for your input though. I couldn't self-pay, I'm a single mom and I just don't have that kind of money, I wish I did... I have heard some heartening things about cigna and ds surgery approval, so I may not be totally screwed, although I will probably have to appeal... I'm willing to fight for this, all the way!

Cigna HAS approved several BPD/DS! On the VSG (Sleeve) forum, many people with Cigna have been approved for this procedure, which is the first part of the 2-part procedure for high risk pts. Cigna has even approved the Sleeve as a stand alone procedure, as it is proving to be the safest, easiest, and most cost-effective procedure out there. The wt loss surpasses the Lap Band and is comprabable to the RNY, without any of those risks, complications, and side effects. Several surgeons are pursuing having the Sleeve replace the LapBand (since there is such a high rate of erosions, infections, and complications with the Band, many Banders are getting revisions to the Sleeve). There is even a movement to have it replace the RNY as the new gold standard because of the excellent safety profile, which dates back to the 70's. Check on the DS board and the VSG board for those with Cigna. There may be some advice of how they got Cigna to approve. Keep in mind, not all Cigna plans are identical, especially if your employer funds it. Also, as the VSG (with and without the DS) and BPD/DS are gaining popularity and more studying coming out to refute the insurance's claims of "experimental," there are a lot of insurances that are now approving it. It may be that you need to supply Cigna with the research and your surgeon's letter shouls also cite research. You may find your insurance changing it's policy very soo. So, don't give up hope. It may not be a "done deal" Kahlua 

Thanks :) I have found out in my whining on various boards, that the BPD/DS which is the procedeure I would like is now covered by medicare, so if Cigna denies it on the basis that is experimental, I can site that as a rebuttal.  A girl on the DS board just had surgery not too long ago using that appeal with cigna.  Also, I have heard that since my plan is from the state (I am a dstate employee) it will be less likely to be denied, something about how the premiums are paid or something, I'm not sure. Finally, My surgeon of choice, Dr Roslin in NY has an incredible office staff who I'm told will do everything they can to get me approved. I am feeling a little bit better now, but I am still very nervous about this.  I want this to happen so badly, and I don't know what I'll do if something stands in my way!!!

There ARE people who have got Cigna to approve the DS. They still don't have it as a part of their policy, but the fact that Medicare, Aetna, and BCBS cover it, Cigna most often gives in on appeal...especially if you get an independent reviewer. Independent reviewers often go with what Medicare covers. I think the fact that you have an extenuating cir****tance (your need for nsaids) will also be very beneficial for your chances). And you're right. I don't think the Lap Band will be very helpful for your BMI. You just need to insist on the right surgery for you. Good luck!

Hi Kris.  Yes, Lyndia fought Cigna and won.  She had I think 3 internal appeals and 2 external.  Don't quote me.  But it was a long haul for her.  We have to keep plugging to try and get these insurance companies to see that the DS is NOT investigational.  That is old school thinking.  I have just submitted my second level appeal to my insurance company.  276 pages worth.  We'll see!!  Don't be nervous.  Just finish out your diet and get ready to fight!!!

GO DS!!

Thanks. Not looking forward to a fight, but at least I am ready for one. 

I'm having the same issues with insurance.I now have aetna but am going to bcbs in jan and neither company cover Vertical Sleeve. I'm going to bite the bullet, i've been approved for a home equity loan and i'm going to Mexico to get the surgery.  I really cant afford it but I cant afford not to put my health first.........