Cigna appvd Band rmvl but denied revision because technical failure wasn't proved??

Wow, this has been some journey. I had the band done in '06 & almost immediately had complications & knew I had made a mistake (I was back/forth with deciding RNY/Band). After having severe reflux & vomiting attack sent me to the hospital in '08 I decided to have a complete unfill& never went back. Not knowing revision was even available as a potential option I continued trying other weight loss methods with the same old story, lose weight, gain back & then some. FFWD to my Bday 5/22/2012 I was, depressed, not happy at all with my body, I was not participating in my own life & decided to go online & found out about revision surgery so I placed a call to my surgeons office & that day started the ball rolling to, what I thought would be my new lease on life! (which is what I had hoped for from the band)
FFWD to present day Cigna has appvd for the removal of the band which I had done 10/12 but won't appv my revision because "technical failure" was not proven smh because I can't wrap my brain around why they appvd for the removal?? Anyway, went through 1st appeal then they came back with "insufficient documented weight loss within 2 yrs" I'm wondering if I should even bother with a level 2 appeal at this point. I may just go ahead so I can say I exhausted all my options. They say I can try again after a yr but unless they change policy I don't see any change. If I go with another ins co maybe we'll see....

Insurance companies can be so frustrating to deal with.  Here is what I found on-line regarding Cigna's bariatric suregery policy:

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.
• 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).
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.

 

So, it sounds like Cigna is saying that there is no proof of technical failure of the band documented on a UGI or EGD.  Has the report(s) from the hospital visit in 2008 been sent to them?  It also sounds like they are saying that there is not enough documentation regarding your weight loss after the surgery.  Do you have all your reports from your first surgeon's follow-up visits (where, presumably, the weight loss is documented)?

If you gave them everything, and they still deny, I would absolutely go with the appeal - what's the worst that can happen, they say no?  They already have!  Force them to spell out why you are denied.

Lastly, if they ultimately deny you completely, then re-apply in a year.  It would be considered a new surgery, not a revision (I imagine, but I could be wrong).  Here are Cigna's requirements for bariatric surgery, which, depending on your stats, might fit you:

 

Cigna covers bariatric surgery using a covered procedure outlined below as medically necessary when ALL of the following criteria are met:
• The individual is ≥ 18 years of age or has reached full expected skeletal growth AND has evidence of EITHER of the following:
*  a BMI (Body Mass Index) ≥ 40
*  a BMI (Body Mass Index) 35–39.9 with at least one clinically significant obesity-related comorbidity, including but not limited to the following:
     o mechanical arthropathy in a weight-bearing joint
     o type 2 diabetes mellitus
     o poorly controlled hypertension (systolic blood pressure at least 140 mm Hg or diastolic blood pressure 90 mm Hg or greater, despite optimal medical management)

    o hyperlipidemia
    o coronary artery disease
    o lower extremity lymphatic or venous obstruction
    o obstructive sleep apnea
    o pulmonary hypertension

• Medical management including evidence of active participation within the last 12 months in a weight-management program that is supervised either by a physician or a registered dietician for a minimum of three consecutive months. The weight-management program must include monthly documentation of ALL of the following components:
* weight
* current dietary program
* physical activity (e.g., exercise program)  Programs such as Weigh****chers®, Jenny Craig® and Optifast® are acceptable alternatives if done in conjunction with the supervision of a physician or registered dietician and detailed documentation of participation is available for review. However, physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.

• A thorough multidisciplinary evaluation within the previous six months whi*****ludes ALL of the following:
*  an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s) and all of the associated current CPT codes
* a separate medical evaluation from a physician other than the requesting surgeon that includes both a recommendation for bariatric surgery as well as a medical clearance for surgery
* unequivocal clearance for bariatric surgery by a mental health provider
* a nutritional evaluation by a physician or registered dietician

Thank you for your response and info.  I am going to move forward with this and see what happens .  I feel like if they appvd the band removal they must have agreed it had to be taken out based on the documentation I did provide & also at this point , I feel the band is/should no longer be a factor so I will stress the facts which is I am still battling obesity & the numbers & comorbidities will attest to this so I'm still seeking treatment.

Any thoughts on this & possibly using one of the appeal letters I found on here?

I think the requirements for band removal and revision are different.  I believe the revision requirements are more detailed and demanding, whereas with the band removal, they simply require "complications such as stricture or obstruction."

As for the revision, the specific requirements they have are listed in my post above.  Normally I would agree with you that since the band has been taken out, it is no longer a factor.  But, the band was just taken out.  If you go that route (of a regular WLS), then I imagine your time starts over again (for showing obesity, etc.).  Keep in mind that the policy is reviewed again in May of this year, so there may be WLS policy changes for Cigna.