I have Cigna PPO

My husband has been working at the same place for nearly 15 years and I've been covered by Cigna the last 4-5 years . So far any surgery that I've needed has been covered 100% and the tests/office visits have been $15 co-pay. Anyone else have Cigna PPO like this and had wls? Did they approve the first time or second? I have 3 heart valves leaking and have to be tested every 6 months to see if any of them have to be replaced. I wish to lose the weight so that I'll never have to have the surgery or at least hold off for a long time. I'm also going to visit with a doctor on my persistant lower back problems and knee pains. A sleep study is being set up for me to see if I also have apnea . Also I was in TOPS for 18 months and only lost about 10lbs. My metabolism is hard to get started, I guess from 10 years of yo-you dieting and exercise is hard for me to do, my blood goes backwards because of the heart valves and I can't breathe.

Laura, Cigna never approves anyone on the first Pre-Authorization request. In fact, it is becoming more and more difficult to be approved for WLS by Cigna in any situation. Currently, they are requiring (2) 26 week, physician supervised low calorie diets, one being in the last 12 months. Further, your doctor must document in your chart at LEAST monthly weigh ins, the number of calories you are on, exercise plan (you have to keep a log), and a behavioral program. I think good documentation would be consultations with a nutritionist or behavioral psychologist to work on eating habits, etc. Here's the kicker. Cigna won't pay for any of the above charges. Worse than that, as of January 1, 2004, many Cigna groups have EXCLUDED surgical treatment for Obesity from there plans. What you need to do is have your husband call his Human Resources Department and request a copy of the SUMMARY PLAN DESCRIPTION booklet. He must ask if there are any AMMENDMENTS to the Plan, in case the Exclusion for WLS was added after the booklet was printed. There is a Yahoo Group called Cigna Squeaky Wheels, where you can read about the trials and tribulations that other people with Cigna coverage are going through. Fight the good fight! Roberta

I did call Cigna and they said that the doc has to submit for authorization. The woman at LivLite said she has a long list of people that have serious health issues and Cigna won't approve them. I asked Cigna for specific info such as length of supervised diets and all of that. The representative said that information wasn't in front of her and that I'd have to submit. Why in the world everyone thinks that a diet will cure us is beyond my comprehension. I know that there are some that won't even try to diet, just want to do the surgery but most of us do want to lose and keep it off we just need help doing so. I can't find the group Squeaky Wheels anywhere. I did read in another post somewhere that a woman was denied and so she went to insurance review board, got some information to send her denial to and they reviewed her claim and approved it. Her insurance will have to cover her surgery now. Instead of fighting I'd just as soon pay for it, if I'm denied even after following their instructions. What insurance usually pays for this? Any one insurance that hasn't caused a big stink first?

Paying out of pocket will cost you at least $30,000. Why wouldn't you fight for benefits you have already paid for? Go to http://health.groups.yahoo.com/group/Cignassqueakywheels/. You can always email me directly too. Do not call Cigna for any information, or listen to what they tell you over the phone. You need to get the information directly from your Summary Plan Description booklet.