Question:
~Not Sure what they are really saying~

I Finally after 3 weeks recieved my denial letter from Cigna, and I was a little amazed at what it said, because after reading it several times, Im not sure what they heck they are saying. *Laugh* Geez talk about feeling foolish. Anyway Im gonna post my letter, and let anyone read it and let you guys tell me what you think, and what I Should do Next...I really just want to throw my hands up but I just cant..Here is the letter........ We are acknowledging your request for a pre estimate of benefits under the above plan for services recommended for the patient.. Based on the information submitted, the plan currently would provide no benefits for gastric bypass. Any Claim submitted is subject to all provisions of the plan.Including eligibility requirements, and benefit amounts, If any, Will be determined on the basis of facts existing when services are preformed. It is understood that circumstances (Change of diagnosis, change in plan of treatment, medical complications) may result in different CPT codws and thus charges different then those submitted on the pre-Estimate Form. ********************************** So there it is, I know that CIGNA PPO has in the past covered the surgery, and im not sure why I even got denied. Anyone with advice, or having dealt with Cigna, please Let me know and send any help *Smiles* Thanks.....    — Ann A. (posted on July 27, 2000)

July 27, 2000
I am not offering this explanation as a pre-op who is just beginning her struggle to obtain this surgery, also but I work as a medical coder and deal with insurance problems, payments, etc. They are denying you. In line two the letter states for gastric bypass. However, they give you suggestions for reapplying. Here is what I would do. I would try to find out more information on what my plan covers. Are they denying the procedure itself? Were the other patients receiving the exact same WLS procedure?
   — JennyLynn A.

July 27, 2000
I am not offering this explanation as a pre-op who is just beginning her struggle to obtain this surgery, also but I work as a medical coder and deal with insurance problems, payments, etc. They are denying you. In line two the letter states for gastric bypass. However, they give you suggestions for reapplying. Here is what I would do. I would try to find out more information on what my plan covers. Are they denying the procedure itself? Were the other patients receiving the exact same WLS procedure?
   — JennyLynn A.

July 27, 2000
Another area that needs looking at according to their denial are the CPT codes used for the procedure. I do not have a coding book handy but that bears looking into. It is ever so easy to make a mistake there. They mention your diagnosis--you see diagnosis codes have to match up with the procedure codes. For instance perhaps your surgeon coded your diagnosis as GERD, and Diabetes. In truth you have GERD and diabetes but you also have joint problems and hypertension. What if your insurance pays for this procedure only for cardiac or respiratory co-morbidities. You see how they could bounce out your diagnosis for not being in their guidelines. Typically when a doc (or staff) file with insurance they only list a few of the diagnosis if there are many. In summation it would be very helpful for you to know more about others claims submitted to this insurance and to try to find more specifics on your insurance's policy. Why not call the person signing this letter and ask her specifically what each sentence in question is refering to exactly. Remember you pay for this insurance you have a right to the services. Make them earn their premiums. Hope this complicated explanation helped.
   — JennyLynn A.

July 27, 2000
Does the ins. plan under Cigna exclude any type of wt loss surgery? Call member services & ask them. Or are they saying that you( your co-morbidities) don't qualify at this time? I would ask to speak with whomever in their Medical Review Dept.& get clarification on this. Your specific ins. plan will list exclusions & if this is one of them (obesity related surgery, etc.) there is no way short of a miracle that it will be covered by ins. Let me know if you need help wording an appeal letter, ok? Hang in there...it's not the end of the world!! It's just a stumbling block!!!
   — Kathy A.

July 27, 2000
Sounds to me like something very similar that I went through with my insurance company (BC/BS Federal Employees)... They wouldn't "precertify" my surgery either but said that as long as I met the "criteria" for WLS in my policy the surgery would be covered ... Get your insurance company to send your doctor a copy of the "criteria" it requires for WLS ... that should give your doc a pretty good idea if they will pay when the time comes.
   — Donna H.

July 27, 2000
I had Cigna PPO and I had a lower BMI than yours and I was approved. However, I called EVERY DAY for two weeks. Did your doctor provide them with enough information about your past trials with weight loss? They requested this on me and it was what decided it for them. I would resubmit -- Cigna DOES precertify this surgery, do not go forward without their approval or they are not obligated to pay.
   — Beth B.

July 29, 2000
They are denying any/all claims related to gastric bypass. If your condition changes, they may consider it. You must have at least 3 co-mobidities. My surgeon started my claim with "possible sleep apnea." I was surprized that he started out with simply a possibility. I have severely artritic knees, diabetes, early retinopathy, early neuropathy in my feet, HBP, shortness of breath and candidiatis.
   — Louise H.

March 28, 2001
Dear Christine, Thankyou so much for replying to my old post *smiles* Since then I did get a approval and am schuedled for this year to have my WLS through Cigna, they denied once, and I appealed and they approved..*S* Thanks so much though..Hope all goes well with you...Good Luck
   — Ann A.