Need help on how to appeal Cigna's denial _HELP!!!

I have been denied twice by Cigna. First was because the In-Network doctor submitted a claim to a non network facility.  We got that straighten out.  Now Cigna has come back again to say I was denied me for the sleeve for the following reasons:

They say medical necessity has not been established because:

1. The documentation submitted does not confirm that technical failure has been demonstrated on upper GI and EGD.

2. the documentation submitted does not confirm that due to technical failure of the original bariatric surgical procedure you have failed to achieve adequate weight loss as defined above at the least 2 years following original surgery (I had the lapband surgery that never worked for me)

3. The documentation submitted does not confirm that you have remained fully compliant with the medically prescribed postoperative nutrition and exercise program.

The doctor is going to attempt a peer to peer review, should I do anything else?  The lapband didn't work for me.  I have high blood pressure, my PCP submitted a report showing my heart is affected by the high blood pressure.  I have tried everything imaginable to try to lose weight and I can't keep it off.  I even bought a dog to walk only to find that I could walk about couple of blocks before hip started to hurt and feet went numb.  I just don't know what to do at this point.

If someone could guide me so I can get approved.

 

Thank you!

 

Gigi

I cant give any advice but I am in the same boat with Cigna in TX. BMI 35 lapband 10+ years ago. Never lost weight. Been in pain with the band for the past several years and I just got the second denial because no technical failure and because there is no evidence to show WLS cures diabetes. I dont even have diabetes!! I am so frustrated with dealing with Cigna. My dr is going to do a peer to peer on Monday but Im not very hopeful for anything except another denial. ARGH!!! I hope it works for you.

Hi there! I had my doctor do a peer to peer review and I was approved within 15 minutes. I have my surgery 11/25. I supplied the doctor with everything I tried to lose weight. Printed out when I joined weigh****chers. I printed out an invoice showing I did acupressure balls to lose weight. Showed when I joined a gym. I mean everything I can think of that I did I gave to the doctor. Don't give up!!!