Cigna Denial

I should have seen it coming... but Cigna denied today?!? They said it was due to lack of Medical Necessity. I called Dr. Srikanth's office and they put me thru to Kay's voice mail. It sucks she has reduced her hours... I hoped for a phone call back today but nothing...

I knew they would deny the first go around... what I didn't expect is the gut wrenching feeling I felt when the Cigna Rep told me. I was breathless and wanted to be sick. I had to hold it together all day at work but since I have been home all I have done is cry... I guess I just call Dr. Srikanth's office again in the morning and Cigna although not sure how it will help... I am going to fight this; I just hurt tonight.

What a major disappointment!!  I can totally understand how you must feel to be so close and then feel like the door was shut in your face.  But hang in there...  I'm sure Dr. S's office has had many insurance denials and will know how to help you jump through the hoops to submit an appeal.  You will be in my thoughts and prayers that you will have a successful appeal and get them to approve your surgery.  By the way, I had Cigna when I had RNY and they covered it.  It may have been a different plan back in 2007 when I had my surgery, but hopefully that's a good sign for you that they do cover it sometimes.  Take care...

My Cigna plan does not exclude RNY, they just feel that so far Dr. S has not proved Medical Necessity. I Called again on Friday and the Cigna rep I talked to couldnt locate the denial but said that a peer to peer had been scheduled, but she couldn't see when. I called Dr. S's office and Kay wont be in until Monday...

Cigna told be that I have two rights of appeal and the peer to peer that can take place. That each appeal could take 45 days... Ugg

I just I just hold tight until Kay can tell me where to go from here. But I am not going to give up!!

~Namaste~

I'm sorry that you were denied by Cigna.  Obviously you will appeal and document the medical necessity.

Just some friendly advice; your primary care doctor may be able to provide more detailed information regarding medical necessity.  I'm assuming you needed a referral to see Dr. Srikanth; that means that you regular doctor felt WLS was warranted.  Do you have any co-morbidities that are documented in your chart like insulin resistance or Type II Diabetes, High Blood Pressure, Sleep Apnea, Arthritis, etc.?  Without knowing the specific policy language I can't tell tell you what they want  but it's common for HMO's to require a minimun BMI of 35 and/or co-morbidities.  I'd suggest asking your regular doctor to write a letter indicating specifically medical issues related to your weight including dates of visitts and the therapy used to treat those issues to date (prescriptions, physical therapy, referrals to specialists, etc), Have your doctor state specifically that these issues are weight related and will improve or completely resolve with significant weight loss.

Your appeal should also include past weight loss attempts and reasons for failure [really it's a which came first the chicken or the egg game; e.g, perhaps you needed to lose weight and so you joined weigh****chers, however, due to metabolic syndrome, inability to exercise adequately etc you couldn't achieve substantial or timely weight loss, gave up, regained any minimal weight loss (in comparison to how much excess weight you need to lose) and more.  Then you tried South Beach, etc. etc..].

It's hard to be patient, but if you get your p's and q's in order, you should be able to win an appeal once your regular doctor and Dr. Srikanth establish medical necessity.

I wish you much success in your journey,

Amy