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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.
HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"
M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)
We LOVE NSVs. Check out this video on NSVs that contains some of our fellow OH members and speakers from the 2013 ObesityHelp Conference, courtesy of OH Member, Beth Sheldon-Badore. Inspiration for all of us as we live our healthy lifestyles every day.
What are some of YOUR NSVs?
I'd be broke with bills than live another year like this.
Lots of luck to you!
on 10/6/13 11:53 am
I will have a revision in February, too.I wondered about this as well, but I will still have my private insurance, so I think I will be ok. I need to get everything and anything done before things change.
Hello, this is my very first post.. I have a question for anyone that will listen. I've been considering gastric bypass for a long time and I finally have a new job with insurance and I've got to a great place in my life and I felt like now is the time. I went to a seminar and it was incredible, positive and informative. I happily started filling out my packet the next day and started to try to line up appointments.
Then I got the call about my insurance. I had no idea about the 5 year documented weight history that would be required. That is the only thing holding me back from insurance helping me with the surgery. I lost my job a few years ago which meant I lost my insurance.. when I got sick? I toughed it out and never went to a doctor. I have no records of being weighed, not from a doctor, walk in clinic, ER, etc. Literally, a $20,000 mistake. I was quoted $4000 with insurance after meeting requirements. Self pay would be $24,000.
I am absolutely crushed. I've been crying for days. I'm keeping the appointment I have next Friday with my MD, I am going to ask her if she will send a letter of Medical Necessity. I feel in the back of my mind that it won't work and they won't approve it.
Have any of you had this happen? Or had a letter of Medical Necessity work for you?
Any advice would be greatly appreciated. Thank you so much.
Hockeymom87 · 0 replies · 618 views
