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'm sorry no one replied to this.  It really depends on each insurance company.  For example, Aetna requires that the 6-month supervised happen within 2 years prior to the surgery.  They have a 3-month option that they require happen within the 6 months prior to the surgery.  It appears that BCBS's medical policy bulletin is silent as to the timing, so, you might make it.

Anyone out there have experience with Medical Mutual paying for a revision/wls?? My insurance (medical Mutual Plus) said they do not cover weight loss surgery of any kind! But what if I am having secondary problems from my original surgery? Anyone know?? Thanks!

I'm right there with you on that one. I only have two of the five years documented. My surgeons office coordinator doesn't seem like she has a lot of hope. At this point I am still pressing onward with all my appointments and pre-op tests. and if it means a medical loan, then so be it.

I'd be broke with bills than live another year like this.

Lots of luck to you!

I'm not sure which insurance you have but don't give up hope my insurance really took a statement from me and my surgeons office of what diets I had been on in the past 5 years.. I had a horrible time when I first started trying to get approval due to me having 2 insurance policies at that time it took me few months to figure out what needed to be done and now I'm approved with a December date... Have faith