Cigna denied me....Can I appeal...Please Help!!

Cigna denied me, they said

"After review of the clinical documentation received, medical necessity for bariatric surgery has not been established because: with the height and weight submitted, your calculated  Body Mass Index is 35 or greater at 37 with at least one clinically significant ailment (co-morbidity). However, there is no documentation confirming that your BMI has been consistently 35 or greater for a period of at least 24 months."

This is my problem in "06" I had no insurance so I didn't go to the doctor. When I got my Insurance in 11/07 I started going again. I do have Curves and WW papers showing my BMI over 35 but I guess they wouldn't use those. I need to have my gallbladder out also so I really want to appeal this...and of course win....but don't know if I have a chance or how I should go about it. I thought maybe my Doctor could call and do a Peer to Peer. But what could he say to get them to change there mind. It would be better for me to have both surgeries done at the same time....less risk

Documented Weight


4/1/06    WW Card  218.4
1/11/07  WW Reg Card 217.6
1/15/07 Curves Red Paperwork 211
11/2/07 PCP    194
2/8/07 PCP 199
2/12/08  PCP 203
4/10/08 PCP 209
4/18/08 PCP 210
and so on up until 11/08

I can't believe they deny you because you are on a diet or sick with gall bladder disease and you lose a little weight that you apparently gain right back. HELP!!!!! Any Idea's?????


Thanks

Dianne

Bless your heart..... You can appeal anything.... However I would ask Vicki the insurance guru... She's so nice and informative. I'm sure she will be along soon.

Good luck

do you have medical records from before 2006?  Cigna says "for a period of at least 24 months", but does that have to be consequtive?  If you have a weight from 2004 or 2005 perhaps that would work. 

Vicki ,   if your'e out there I sure could use any advise you may have!!!!!!!



Thanks,  Dianne

 If they say they want documented proof why wouldn't WW and curves count? What purpose would it serve for WW and Curves to lie about your weight. I'd write an appeal and include those documents you do have, driver's license pictures, pictures with dates on them, anything to establish that you've been MO for 24 month plus. Like someone else said they never said it had to be 24 consecutive months, do you have anything from a clinic or ER? Best of luck. I'd appeal, most of the time they say no the first time. The just want you to go away and give up or die. Don't let them win. Medi-cal and the NIH don't state anywhere that you have to be MO for any certain period of time. You should include that in your appeal too. 

I know it really is stupid the way they think.....I am going crazy trying to figure this out. I know there has to be a way to appeal it. But The denial clearly says "However, there is no documentation confirming that your BMI has been consistently 35 or greater for a period of at least 24 months." It is interesting that NIH doesn't state it that way. It really makes no sense that they would make you stay overweight because of this stupid rule....so you can get more co-morbities.


Thanks for writing

Dianne

Vicki

Thank  you so much for getting back to me. My doctors office did send some more papers over. I have not been able to talk with the girl in the office she wont be bac****il Tuesday. I am not sure what a PM is????? Sorry.....

Dianne

 PM is personal message. You can just hit contact under where they posted a reply to you.

Diane sorry just now saw your cry for help, kinda been bogged down for the last few days.  If you have all these cards and proof I would appeal this with the additional information you have if you need help send me a PM here on OH