Revision band to RNY... worried about denial (cigna and slippage)

Yes and I have 2 months under my belt for the supervised plan, as well as all the other requirements (psych, nutrition, class etc...) So I suppose i would just need 1 more month as they require 3. So everything is done, they are just trying to avoid the last month and speed it up due to the slip. 

Did you submit your pre auth yet?

I have two months down as well, but have not yet done psych, nutrition, classes (all later this month, appointments made). I have not yet submitted the pre-auth yet, as I was under the assumption we would have to send the whole package (3 month supervised, psych, nutrition, classes, upper GI results showing slip etc.) before they would even look at it.

Were you able to submit a pre-auth? Also, I am unsure as to whether or not the surgeon will classify mine as a slip...as the only problem at this point (besides my symptoms) would be the horizontal position. What did your doctor say, did he agree that it was a slip based upon the position/symptoms? My plan also requires only 3 months. As far as the supervised plan, do you see your PCP or someone else associated with your surgeon's office? What all do they include for each recorded visit?

Thanks for the reply. I swear, I feel so alone sometimes. I really feel like nobody understands how frustrating waiting on something so uncertain for so long. Glad to be on here now.

So yes, he did call it a slip. They are submitting for pre auth this week. I just got an email from my rep asking who I saw for my band. I know we have to show full compliance with it, but I was unfilled 6 years ago when I was pregnant and saw the prev doc over a year ago and he too reccommended a swtich or removal but at the time I had different insurance who denied so i just thought I was screwd and did nothing, been miserable ever since. I know my plan has a 10,000 max so I really need to do this all in 1 shot. As far as supervised wl, Im just seeing my regular GP and he is weight me and reccomending food. Per my docs office all they really need is some sort of documentation and so that should be enough. 

Im in tears right now, because they had to schedule a surgery date before submitting and I have had nothing but shakes for the last week as they were trying for June 2nd. But now I am just super concerned that it will not go through and Im in shake hell for nothing. 

Ok, that's good that you've got an acknowledgement from your doctor regarding a slip. It is the surgeon's job to also fight for you with the insurance, so that is good news that they can prove medical necessity. In terms of showing full compliance, I would let the current rep know about WHY you unfilled and WHY you were unable to do anything about it with your old insurance. Not your fault, so you shouldn't be held accountable for that necessarily. It may not cut it, but hey, you tried right? However, you might want to share with your rep who will document all the things you did try: paleo, atkins, exercise regimes etc during those years you were not able to "be compliant". 1 surgery is usually better than having 2. Every time you go under, there are risks. The case could be made for both situations, where your body might need time to heal...but I just don't like the idea of getting cut on twice. Financially makes better sense as well. 

For the supervised plan, you might want to ask your GP to add in any exercise you've done as well (read that they want that detailed too, or some evidence). Not sure if needed though.

Why did they schedule the date before submitting? It is good you have a preliminary date...my surgeon won't schedule until I have some type of approval in hand, so it is frustrating not to know. To boot, my surgeon hasn't even seen the upper GI results yet...so I have no idea whether or not he'll agree with the practitioner if it IS a sip.

Each time these complications happen, time is needed off work/regular life etc. I know how you feel about the shakes, you really start to lose your mind being limited to liquids only. The best you can do is this: make sure you are doing all you can (you are), look at the shakes as a break for your body that is clearly having issues with a slipped band anyway, added bonus of losing weight, you will be ready if your surgery date comes through AND once your surgery is completed, you won't need to readjust to a liquid-only diet. Another thing: your body gets tired of eating only sweet tasting stuff (assuming you are drinking protein shakes)...try some plain protein powder in some cooled-down chicken broth, miso broth etc. If you add something salty tasting, or umami, your body will likely be more satisfied. Jarrow Unflavored Whey Protein

Does the office have a self-pay option? For example, I'm willing to hedge my bets that Cigna would absolutely pay for the band to be removed...you've proven complications with a slip already. No problem. For the revision, however, that's when things become questionable. You have all of the documentation they ask for, but ultimately it is Cigna who "interprets" your data as being enough or not. If you did have a self-pay option, you might think about starting to save up in the event where you would need to pay for the revisional part. The doctor could work with you on a lesser rate since he knew part would be self pay. So, in short, denial is not the end of the story necessarily. Not to mention, I've read through the forums and have seen lots of cases where folks have successfully appealed Cigna and won...it was just time consuming. Then again, saving up is time consuming as well.

Take heart, and don't allow your low blood sugar to get the best of you. Uncertainty is the worst feeling of all sometimes. Know that once the pre-auth is submitted, Cigna will make the decision and you'll know sooner than later! I know how you feel, you must remain positive because at the end of day, you can never take time spent worrying about things you have no control over back. Easier said than done, right? 

Keep me updated. I'll keep you in the loop as well. I'll post here after I get the results, and let you know if there's something you could try although by then you guys may have already submitted.

"If you're going through hell, keep going."-Winston Churchill ;)

As far as excersize goes, I am doing what I can and they have that down as I am limited, I have a total right hip replacement and severe arthritis plus a cam lesion in the left that also needs replacing, so its hard to get a full workout with disability. 

The insurance is more likeley to approve with a date already set. This is from cigna, also I talked to them last night and he siad this is considerd a fix, so we may not have to meet all the critera as a new patient would. He said there were like 4 critera  I think it was that we covered the procedure, that I was in compliance, that there was proof of failure and I can not remember the other one but it was somthing similar to coverage. So if this is true then we will be good as my previous doctor sent over all the medical records showing all the fills/unfills etc... and his final appt he also reccomended a revision, only my ins at the time denied due to 1 surgery per lifetime per member and at that point my band had not slipped. 

I definetly have broth when I get the "food" cravings. So heres to hoping all my ducks are in a row. 

I'm waiting on approval for a lap band to sleeve revision and I also have Cigna. Here are the qualifications that Cigna requires.

Reoperation and Repeat Bariatric Surgery:
Cigna covers surgical reversal (i.e., takedown) of bariatric surgery as medically necessary when the individual develops complications from the original surgery such as stricture or obstruction.
Cigna covers revision of a previous bariatric surgical procedure or conversion to another medically necessary procedure due to inadequate weight loss as medically necessary when ALL of the following are met:
• Coverage for bariatric surgery is available under the individual’s current health benefit plan.
• There is evidence of full compliance with the previously prescribed postoperative dietary and exercise program.
• Due to a technical failure of the original bariatric surgical procedure (e.g., pouch dilatation) documented on either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD), the individual has failed to achieve adequate weight loss, which is defined as failure to lose at least 50% of excess body weight or failure to achieve body weight to within 30% of ideal body weight at least two years following the original surgery.
• The requested procedure is a regularly covered bariatric surgery (see above for specific procedures).
NOTE: Inadequate weight loss due to individual noncompliance with postoperative nutrition and exercise recommendations is not a medically necessary indication for revision or conversion surgery and is not covered by Cigna.

I did not go through the 3-6 months of dieting again either nor did I do the psych eval or nutritional counseling this time around.

Hi there,

For the: • There is evidence of full compliance with the previously prescribed postoperative dietary and exercise program. part of the qualifications, what have you done to prove that out of curiosity? I'm still waiting to hear back from my surgeon, but am a bit worried about getting that evidence together because this seems to be largely up to their interpretation, no strict guideline given on what you can and can't present for that.

Thanks.

Im curious as well, I mean my surgery was over 6 years ago and I did get seen and get filled and unfilled regurlarly until I ran into complications. 

They are talking about whether we were compliant postoperatively after having our first surgery, the band. What they are wanting to know is that the first surgery was a failure due to the band and not us. I saw my previous surgeon frequently and he documented my progress. That should be sufficient.

Ok ya that sounds like me, I saw him regularly up untill a few years ago when even he reccomended a revision.