Cigna...HELP!

Hello All,

This is my first post. I just joined ObesityHelp and I am thrilled to be here!

I am trying to get approval from CIGNA for a VSG. I am 22. My BMI is 57 and I've met all of the requirements by CIGNA. I did 3 months of weighing in starting on December 14, 2012. My second weigh in was January 21, 2013 and my third was February 22, 2013. I lost 9 lbs overall. I gained a little over Christmas and in January, but lost that weight +9 additional pounds. Anyway, I also was being monitored by a dietitian, and a psychologist. I had a psych eval and passed with flying colors. I had also initially talked to my PCP on October 25, 2012 about wanting to get the Sleeve and about what my options were and she was very supportive. So on February 22, 2012, my paperwork was faxed to CIGNA.

I have been calling them every single day (sometimes 2X a day) to follow up on the status of my claim. Well yesterday, March 1, 2013, I found out that my claim was being passed on to a medical examiner for revision. So that means the CIGNA nurse denied it initially. The basis for her denial was this:

-I did not meet the 3 month weight loss monitored program 

-I did not have a psych evaluation

-I did not have a letter from another doctor giving me approval for the surgery such as my PCP

So, I know the first 2 reasons are not valid and can easily be sorted out. The third reason is completely my fault. I thought the weight loss center would contact my PCP to get the letter for the packet before they submitted the request to the insurance...they did NOT do that. I'm freaking out here. I was told the medical examiner would review my claim on Monday or Tuesday of this next week. I know that if I do not have the letter from my PCP that my claim will be denied. If I can manage to get the letter to CIGNA via fax from my PCP then there's hope, but I'm scared that it won't make it to CIGNA before my claim is denied.

I was wanting to get this surgery on my spring break because I'm a teacher and that would give me plenty of time to recover before school starts back up.

Is there anyone out there can give me some advice? I really need it.

Best,

Lindsay

 

They may have you on the 1st issue, too.  Make an appt today to have a weigh-in on March 14.  That way, you can show 90 days (3 months) of monitored weight loss/weigh ins.  Right now, since you started on December 14, then January 14 counts as a first full month, February 14 counts as a 2nd full month, and March 14 will count as your 3rd full month.

Also, are you sure that your psych eval results were included in the packet?  If not, get it in now.  Same with your PCP. 

Hopefully, with your BMI, they might let you go through without technically meeting all the requirements.  But, honestly, I think they will initially deny you until you meet all their steps.  So, that means resubmitting right after March 14. 

Good luck!!!  I know it is so frustrating!

How did you get CIGNA to even review your paperwork? I finished all the "steps' to a tee...and when the hospital submitted the paperwork, they denied th case saying CIGNA doesn't cover WLS??  That the person the Hosp initially spoke to and said they did was wrong---so after more than $500 in tests and fees and co-pays...I'm nowhere near getting this done...I almost cried...Just curious I suppose.

Is your policy a group policy or an individual policy?  Most, if not all, individual policies exclude WLS.  If you have an individual policy, then this is the reason that you can't get CIGNA to review your paperwork.  I'm not sure there is anything you can do to get them to change their decision on this.

 

Cigna does cover WLS but perhaps your policy does not.  WLS is an additional rider on your policy, it is very expensive.  Most employers do not wish to pay for it.  They can't just cover one person, it's all or none.  Without that rider you won't have WLS benefits.  Most do not.  :o(

So Cigna does offer WLS benefits, your employer apparently opted not to purchase the rider.

That is probably the case...Thanks!  I'm already going through the process of getting it done in Mexico. lots of great reviews of the doctors there, the facility is state of the art---hopefully will get it done by end of July. This was my plan all along if Ins refused to cover it....Thanks for the response!

Lindsay,
This sounds just like what I heard from Cigna. Were you granted approval? Do have any advice for me? I have a tentative surgery date of July 16.

Thanks,