Help with Insurance Company Issues

A conversion from lapband to RNY was denied by CIGNA. It's a long story but the denial was because the insurance compamny doesn't think I was successful enough with the lapband. My doc has scheduled three appointments with the insurance company doctor to discuss. This doctor is supposed to call my doc.  I discovered this morning that the insurance company doctor has not called my doc now for the third time when they've had a scheduled appointment. I think they are stonewalling the entire process.

I don't know what steps to take next. I called the insurance company today and all the docs and nurses that schedule these calls weren't in so there isn't anything I can do untl Monday. Does anyone have suggestions about what steps I can take next? My husband is going to call the State of Vermont Benefits office and ask them to intervene and or file a complaint.

Thanks,

Andrea

So 41 views and no advice? I'd love to hear from anyone who has ideas about how to proceed!

Thanks!

Based on the website they only cover revision under specific cir****tances - It sounds like the documentation provided by your provider did not supply sufficient information to make a determination.

CIGNA covers revision of a previous bariatric surgical procedure or conversion to another medically necessary procedure due to inadequate weight loss as medically necessary when ALL of the following are met:

Coverage for bariatric surgery is available under the individual’s current health benefit plan.

NOTE: Inadequate weight loss due to individual noncompliance with postoperative nutrition and exercise recommendations is not a medically necessary indication for revision or conversion surgery and is not covered by CIGNA.

•

 

• There is evidence of full compliance with the previously prescribed postoperative dietary and exercise program.

 

• Due to a technical failure of the original bariatric surgical procedure (e.g., pouch dilatation) documented on either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD), the individual has failed to achieve adequate weight loss, which is defined as failure to lose at least 50% of excess body weight or failure to achieve body weight to within 30% of ideal body weight at least two years following the original surgery.

 

• The requested procedure is a regularly covered bariatric surgery (see above for specific procedures).

 
Thanks. I am really thankful for your reply. My problem is they are saying I wasn't fully compliant with my other doc. This is because he was abusive and I just couldn't bear to go see him anymore. My doc is trying to do a peer to peer review. I'll let you know what happens. I am really down right now.

File a clinical quality complaint with the insurance company for one thing against the old doctor - be specific, especially if he is a network provider/

Get copies of your old records - there should still be documentation in the record of compliance with food and exercise plans etc which it sounds like what they are looking for.  If the records do not refect this, do you have your own copies (food and exercise diariries) for the time frame in question to show that you were compliant with the program and still failed to lose weight.

 Thanks for this information too. I appreciate it.

If this is the case the ins co is kinda right.  It is YOUR responsibility to either stand up for yourself and not tolerate the abuse or find medical care elsewhere.  Avoiding it all is not the way to go.  I assume you are seeing another doctor now?

 I am working with another doc now. You are right in that I should have stood up for myself, but I didn't because emotionally I couldn't. Specifically because the dynamic with the doctor was very similar to the dynamic between my father and within my family with shame around weight. Of course at the time I couldn't see that. Bottom line, I was just thinking this earlier today. I wasn't psychologically ready though I thought I was at the time. I am writing a book about my experience. In it one of the things I am doing is making recommendations for further and longer psychological screening. For example, if I had to think about and write about defense mechanisms that might kick in when frustration occurs I might have foreseen this.

Anyway, it was a learning process. If I am able to have the surgery, I know now that I am ready in every way. 

Just a suggestion.  Have you called your employer's benefits department? Maybe you can let them know that you are attempting to have CIGNA and your Dr work together and that CIGNA has missed the appointments several times.  They should have a vendor manager that can escalate the issue.  If it's happening to you it's happening to other members and that is poor customer service.

Thanks for the suggestion. We have called our benefits office weekly and they have called CIGNA. My doctor continues to try to reach them. Then CIGNA says they had appointments with the doctor and the doctor isn't availaible. The doctor says he is availalbe at the agreed upon times. CIGNA hasn't called him and when he tries CIGNA's doctor doesn't take his calls.

I do have another insurance company I can try. I'm currently under my husbands insurance. I can choose my employers insurance. We are going to give it another two weeks for my doc and CIGNA's doc to talk. Then I am switching to MVP. MVP's rep for my company said the surgery would be covered.

It's been 10 weeks since the initial denial that this has all be transpiring. Thanks for listening and for your advice and support. I appreciate it.