Question:
Got my denial letter..

Cigan HMO sent me my first denial letter and it says: -------------------------------------------------- For obesity surgery to be considered, there must be evidence that the member is at high risk and has failed less invasive methods of weight loss. Based on the 1998 NIH/HNLBI consensus report and similar evidence, CIGNA requires documentation, by a valid dietary log or diary, of multiple programs of adequate duration (at least two 6 month progams, including one recent progrm), which include professional supervision, recognized interventions (including a minimum diet therapy, and and preferrably also exercise and behavior modification), and regular follow-up (at least monthly), with weigh-ins, review of compliance/progress, and ongoing modification of the plan as indicated. (Prescription of weight loss drugs is considered an adjunct to other measures and does not by itself constitute an adequate program.) And if the member qualifies for surgery based on such evidence, the member must also be deemed to be an appropriate candidate based on a multidisciplinary assessment, which includes a psychological evaluation of the member's ability to comply with post-op regimens and adjust to dietary, physiological, and behavioral changes following surgery. ------------------------------------------------- I have records going back years of diet attempts, BUT I don't think any of them lasted 6 months... I sent the insurance company copies of my dr's notes, BUT basically they were all about prescriptions of adapex, and not much writeen about diet, so maybe I should go back to that doctor and get him to write a letter explaining the diet he had me on. Is there hope here?!? I can CREATE food journals for 6 months, I have weight watchers journal books to use for that. I just think its rediculous to expect someone to stay on a diet for 6 months when all it does is make you feel like a big fat failure... HELP...    — kjonhjk (posted on April 18, 2003)

April 18, 2003
It has been my experience that CIGNA HMO rarely gives approval for WLS when the covered individual is handling their own appeals and lacks perfect diet documentation. However, there is hope! I spoke with Kelley Lindstrom (from www.obesitylaw.com)just this afternoon and she agreed with me that CIGNA HMO (especially in Texas) is the most difficult company from which to get approval. She stated that her office has very little luck gaining approval for patients until they get to the grievance committee (which comes after all appeals are exhausted). At that point, they HAVE been able to get many of the denials reversed. I strongly suggest you find professional representation to handle the appeals and greivance process for you. If not Kelley and Walter Lindstrom, then someone with experience, because it is truly going to be an uphill battle for you. Another option is to change insurance provders. I appears that it is much easier to get approval through CIGNA PPO if that is an option for you. (That is my backup plan if the Lindstroms don't win it for me at the greivance level.) In any case, DO NOT GIVE UP!!! That is exactly what CIGNA is banking on. Be relentless in your pursuit of good health!
   — Karen P.

April 21, 2003
I received this same letter, except since I have a CIGNA Pos plan, it says at least 12 weeks. My suggestion...get out your provider list and start calling all of the PCP's listed. You should come across at least one who will be willing to monitor you for the required six months. And, since your insurance company requires it, the visits should be covered. I know exactly how you feel...I want my surgery RIGHT FREAKING NOW! I've been thru YEARS of monitoring, but not six weeks in the last calendar year. I guess six months is worth the wait...Then they'll have no reason to deny you! Kimberly
   — Kimberly S.