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.

Hi guys :) So, I saw my surgeon yesterday and I basically had my mind set on Gastric Bypass. She asked me if I was a sweet eater(which I'm really not) and a few other questions and finally recommended the sleeve. One problem; Blue Cross does not cover it yet for people with a BMI between 40-50. So,  now I am stuck. She said the RNY would work also, but the sleeve is not as risky. Now I am torn, because she said I could wait, she feels that my insurance will eventually cover it. What should I do? I know I have been overweight for a long time, but I am tired of waiting, and who is to say how long it would take for Blue Cross to agree to cover it?  Have any of you fought it and won? If so, what did you do?

Oh yes. I had this issue.  I had to follow a 3-month program.  I was not required to lose weight, but I knew gaining weight would be a problem.  About 6 days before my final weigh in, I saw that I had gained 4 lbs.

I immediately went on a strict "diet" along with taking Alli pills I still had in the cupboard.  When I weighed in, I was only up 1 lb.  The doctor wasn't concerned about that at all.  He told me as long as I didn't gain significantly (5 or more lbs.), everything was ok.

it sounds like it will be coverd if you have a BMI over 40 for at least 3 years. It was under that that it said OR and then the stuff about the transplant and so forth. That sounds like it is if your BMI is less, then you have to have had some of those issues.

Aren't insurance companies so confusing? I'd give them a call to verify, but it sounded to me that if you ahave an over 40 BMI then it is covered (unless I read it totally wrong!). I'd love to hear what you find out.

Wendy

Okay well nevermind. I got too carried away when I was first reading this and missed the whole part where you had to have either had a transplant or one of the other issues to qualify for the sleeve. I am sooooooooooooooooooooo bummed. What is their deal with this anyway I just don't get why they don't approve it but have no trouble approving the RNY and the band??? UGH drives me nuts!