Denied by Cigna

I am a little ticked I have been denied wls thru insurance provider cigna.  My BMI is greater than 40 and have 1 co-morbidity.  Well I knew they required 6 months of weight management supervised by a doc so I started a program at the surgeons office. However, I also did a weight management program back in 2007-2008 thru another doctor in which I lost 70 lbs.  I had all of these records forwarded to my current surgeons office.  I attended this program for about 8 months every week.  I kept a food log for the most part and doctor took notes and everything.  All of this information was submitted to Cigna along with all the other paper work they required including note from my primary care doc, psych eval, current nutrition visits etc.  Well I got denied.  The surgeon’s office did a peer to peer review but again they same doc or nurse reviewing my case still denied my request saying the weight management program I did was not in the last 2 yrs.  Which is one of their criteria.  Ok so I receive the denial letter and I saw the terms for the denial see below They mentioned the failure of a weight management program in the last 2 yrs as however, they went on to say of the person has long standing morbid obesity evidence of a weight management program in the last 5 yrs is sufficient. 

You mean to tell me they couldn't let a few months go for the 2 yrs?   Why wasn't my weight management program information sufficient for the 5 yrs?  I know it said long standing obesity but when i called Cigna for a definition of what they deem long standing I couldn't get an answer.  

 I am feeling a bit discouraged at this point has anyone run into this problem?  Is this the true stall tactic by Cigna.My next step is to appeal in January by then I will have completed the program at the surgeon’s office in which I was doing in parallel along with current submission.  I have also asked to receive some medical records from old doctors dating at least 10 yrs back.  I am going to see what happens next.

I thought you were talking about me for a minute... I am in the same situation... pre-cert denied, appeal denied all because the physician supervised program wasn't to their liking... my doc and surgeoun think its absurd but what can you do... I restarted a physican supervised program in August and hope to start over mid January.

I was also denied for this same reason with my insurance but Nov 3rd will be my last appointment for this 6 month go around and I will be appealing then. When I got the denial letter this week finally and realized this was all that was holding me up I am gunna try to appeal it.

My PCP has been documenting very carefully the last 6 appointments she has had WLS so she knows the ropes and I am hoping my appeal will go smoothly otherwise I will have to start another program for weight loss and wait another 6 months which might drive me crazy.

Would it be an appeal or a resubmital of the application with all the documentation.

     I got the same run around from BCBS.  They gave me a tentative approval but I needed to complete a 6 month (180 day) diet.  I had completed 5 months with the WLS's office when we were advised that BCBS had just changed their requirements and I had to complete the diet with my PCP, not the surgeon.  I had to start all over again.  Just to be on the safe side, I also joined Weigh****chers.
     I just finished my second 6 month diet.  The WLS's insurance people sent in the info along with a very nasty note from my PCP and I immediately received an approval.  I have a surgery date set for 11/29.  However, I won't believe it until the surgery has been completed and I wake up in recovery with my guts altered.
     I cetainly wish you the very best of luck and happy appeals.  I know how disappointing and frustrating the whole process can be.  Just remember, that is what the insurance company is counting on, that you will get frustrated and just walk away!

I was finally approved on resubmital of the package. Nothing changed except for the signature on the weight management program letter (doctor signed in stead of nurse)

Oh wow congrats!  So you didn't have to file a letter of appeal or complete the 6 month you were anticpating on finishing in Jan?

I hope im approved on resubmittal if not I will have my pcp write a letter stating I have completed 6 months but im definitly at the frustrated point im running out of days left this year and my insurance has major changes in jan with a new plan year.

Just keep working towards it. I had finished the 6 month program with my doctor but the insurance company did not like the way it was documented.  I restarted a new 6 month program and got 3 months into the program, when I got the call that the insurance company had reconsidered and approved it.