CIGNA RELAXING?????????

The insr lady with my doctors office returned a msg from me yesturday. Durring the msg she adv me that Cigna is starting to relax their stand on WLS a little...  They're still rather addimit about the 6mo sprvsd diet.. But, now they're saying that they only need 2 yrs medical recorders..and now the new thing is that the will relax the approval proccess a bit if you can provide proof that you have fallowed weigh****chers anytime with in the last 5 years. (Meaning submitting the books, the weight charts, rcpts etc.) It's nice to know that they are going in this direction and atleast relaxing a little bit,,, BUT,, HONESTLY WHO SAVES THIS STUFF???????????????? But,, if you have hold on to it if you're seeking apporval it maybe helpful.. 

That’s good because I’ve heard some real horror stories about Cigna. What these insurance companies don’t see is that they end up saving millions in the long run! It’s proven that a healthy employee is a happy to work employee and is less likely to retire sooner!

As far as I have experienced Cigna has actually been very helpful durring this process. I had heard the stories to even with more major things.. But, honestly I cant complain too much.. The sprvsd diet is a little much but,, Im on that now,, and honestly they all seam to want that and if you want the truthe its not that bad.. 6months to prove that I can hand life after surgery is fare I think.. We'll see I might change my mind the further I get into it. But, their getting a good rating from me right now.. But, I do work for a HUGE company that  probably one of the major accounts... So it might make a difference. We'll see..

What exactly does your 6 months physician assisted weight loss program consist of?  I was first told that I could go to my PCP for my visits and then when they were over my surgeons office said that they needed to be with a nutritionist, what did Cigna tell you? Thank you for your help.

Oh I have to be honest I didnt do that much leg work when I checked out insr coverage. All I did honestly was call their 800 and ask if it was covered and what the stipulations were.. They were very helpful but honestly until my Doctors office called to varify insr and what doc were needed to get approval they really took the time to break it down for me... It has to be 6mo sprvsd with a dietitian.. I am fallowing that up with 6mo with my PCP to cover all bases.. I am leaving nothing to chance. So I see the dietitian for the couceling part and she also monitors my progress. I see my pcp who also evaluates the physical part... Thank goodness I have a LOW co pay for both..  But, the sprvsd diet from what I gather is rather important.. The its not something that you want to take littley with Cigna.. What ther are honestly looking for is "CAN YOU STICK TO THE PLAN" and "ADJUST TO THE CHANGES AFTER SURGERY". So they do require a moderate amount of weight loss durring the sprvsd diet. I know it makes honestly little to no sence to you and I.... But, in my case my doctors office suggested that I loose aprox 15-20% of my current weight prior to applying for coverage.. Thats based on my Height and Weight (over all BMI) this might a probably is different for everyone.  They gave me a form to take to the dietitian that I am to have them fill out each time I see her that show what needs to documented for Cigna.. Its Pretty unversal from what I gather with most of the insur co with this req.. Maybe it will help you..

Medical Weight Loss Progress Notes

 

Name_______________________________________ Date__________________________

Weight__________________________________ Blood Pressure_________________

Change in Weight since Last Visit_____________________

 

Pharmacologic Therapy (Xenical, Meridia) Drug_______________Dose__________mg

Physical Activity/Exercise Plan

 

Gym____________x’s week Walking/Running__________x’s week

Aerobics_________x’s week Exercise Videos___________x’s week

Curves___________x’s week

Inability to Perform (Comments)________________________________________________

Recommended Modifications_____________________________________________________

Nutritional Therapy

(Include notes from Diet Plan)

Weigh****chers LA Weight Loss

Weigh****chers LA Weight Loss

Jenny Craig Eat Right

Medifast OptiFast

Other______________________________________________________________________

 

Compliant / Active Participation with Diet Plan Yes No

(Patient has achieved a 15-20% wt loss during diet)

Recommended Modifications_____________________________________________________

_____________________________________________________

 

Total Daily Calorie Intake________________________________________________________

 

 

Provider Signature_________________________________ Date______________

 

 

Name______________________________________ Date__________________________

Diet Modifications (Mark Items Instructed)

(Mark Items Instructed)

 

Eat Breakfast Daily Choose Olive Oil or Pam Spray

Eat 5-6 Meals Daily Avoid Butter and Margarine

Avoid All Trans Fat Use Whole Grain Products Instead of White

 

Eat 5 Servings Fruit/Vegetables Use Calorie Free Beverages (Diet Soda,

Sugar Free Juices)

 

Try New Fruits/Vegetables Cut Back on Regular Soda Consumption

Choose Fresh Fruits Instead of Juice Total Fat Intake Between 20 - 30 % of Calories

 

Bake, Broil or Grill Meats Avoid Simple Sugars

 

Increase Dietary Fiber Include White Meat/Fish at Least 5 days a Week

 

Consume 3 Cups of Low Fat or Keep Saturated Fat Less than 10 % of Calories

Non Fat Dairy Per Day

Drink at Least 64 ounces of Water Daily

Limit Added Fats Do Not Eat After ___________ PM

 

Behavior Modifications (Mark Items Instructed)

(Mark Items Instructed)

 

Eat on 10 Inch Plate Do Not Eat While Watching TV or Reading

Measure Food Plan Menu for the Next Day

Read Food Labels Do Not Grocery Shop When Hungry

Use a Food Journal Daily Make a Grocery List

Use an Exercise Log Daily

Other Behavior Modifications__________________________________________________________

____________________________________________________________________________________

Comments (Progress or Lack of Progress)________________________________________________

____________________________________________________________________________________

 

Provider Signature_________________________________ Date______________

 

 

 

 

James M. Kane, M.S., M.D., F.A.C.S. James M. Kane, Jr., M.D., F.A.C.S.

Peter C. Rantis, Jr., M.D., F.A.C.S. Paul J. Guske, M.D., F.A.C.S.

Jonathan W. Wallace, M.D., F.A.C.S.

 

 

 

Dear Physician:

Our mutual patient is considering surgical weight reduction and requires a medically supervised diet. Many insurance companies are now demanding a six to twelve month documentation of compliance with medically supervised, non-surgical methods of weight loss. These methods include nutritional therapy with a very low calorie diet, behavior modification or behavioral health interventions. Supervised increase in activity, pharmacologic therapy, unless contraindicated, and maintenance support are also necessary to meet insurance criteria, and patient adherence and progress must be met.

Please be very specific about any instructions given to the patient when charting in your clinical notes. The insurance company will request the notes for review, and if they do not have the above criteria in the notes, the insurance company may deny the patient’s request for surgery. Upon completion of the patient’s medically supervised weight loss program, our office will provide a letter of medical necessity. Included in this letter is a summary of the diet, behavior modifications and outcomes.

Please find attached several tools to help you instruct the patient on all aspects of the supervised diet. Include this as part of the patient’s medical record every month.. Thank you for your cooperation in this matter. If you have any questions, please don’t hesitate to contact me.

Sincerely,

 

 

1614 W. Central Road · Suite 105 · Arlington Heights, IL 60005 · Phone (847) 255-9697 · Fax (847) 255-9735

800 W. Biesterfield Road · Suite 101 · Elk Grove Village, IL 60007 · Phone (847) 290-9200 · Fax (847) 290-8764

 

www.suburbansurgicalcare.com

Thanks for posting this.   I have Cigna and my policy has a very strict exclusion for any type of WLS. :(   I have been to see my PCP and she stated that I would need to just weigh in monthly.  *eyeroll*  Clearly that won't do it.   Can anyone give me some information about where to start?  If my Cigna policy has a very clear "NO WLS" no exceptions clause, then how can I even get them to give me the information I need to do the 6 month diet plan?  Do I start by having my PCP write a letter stating that she thinks it's in my best interest??   I also have another doctor, my obgyn who thinks the surgery is a good idea....as does my psychiatrist.... It's good to hear that they are relaxing some requirements...I am still scared though, that they won't approve me at all!!   I just don't even know where to start! I have done WW twice, and lost over 120 pounds both times.....I will go by the WW I attended and see if I can get  a copy of my records.......I know when I went back the second time they still had my chart from the first time! Thanks for reading!

I'm really sorry to be the bearer of bad news but my understanding is that if you have an exclusion its a cut and dry "no go" (in which case the 6-month diet would be irrelavant.) That is the company you work for, more than the insurance, in your case, Cigna. They have chosen not to pay for that in their policy to cut cost. I think the only appeal you have is to your HR dept. Anyone else chime in and help if I'm wrong because I would hate to give bad advise.

Sorry but an exclusion means it is not covered. You have to take it up wiht your employer. Our policy had an exclusion and I ended up paying ca****'s worth it in the end, tis been 3 years and it has almost paid for itself. We are in debt up to our eyeballs, but who isn't? Anyway, I continue to drive my old car since my loan payment for surgery is the monthly payment for a new car!

Put your energy into finding a funding source, you wil lnto win with the exclusion, sorry.

 

 

Bonnie

I agree with the lady above.. Thats what stopped me the first time from having this done. It all has to do with your companys group medical policy,, and what your indavidual plan allows. If there is an exclu to your policy there is very little that you can do.. However that being said,, I have chatted with some people who have challenged this and have gotten it covered. How you do that is anyones guess. I know atleast two of the poeple I talked to that did that had MAJOR CMBs and it was easy for them to write a letter PLEADING for coverage.. Im sorry that your stuck in that situation. What I might do if you're not in a position to pay cash is start a 6mo sprvsd plan.. Make sure thats its docd in you medical file.. That way if that ever changed with your plan you have that one down. Ya never know you might be the one of us who beats this thing  with out WLS

So is there nothing that Obesity Law can do either?