Question:
Does your insurance company have a right not to tell you what their criteria is?

I have Cigna PPO and i was denied because patient does not meet the established criteria.. Thanks for your help. Dawn    — Dawn T. (posted on April 4, 2001)

April 3, 2001
Did you try calling member services and asking what their criteria is? They may not list it in their denial letter, but they will usually tell you when you call and ask. Your profile says that your BMI is 47. You most certainly meet NIH requirements, so I would appeal. Good luck!
   — PT LawMom

April 4, 2001
I was unable to obtain the reason for my denial from Blue Choice until I got the State Department of Insurance to ask them. After several letters between the Dept. of Insurance and BC they finally (after my insurance had expired) let us know that Blue Choice uses a large body frame for their criteria... even though they had no clue that I have a medium or average frame so that I was 10 pounds too light for surgery..... However, (thank God) my new insurance covered the surgery.
   — audra H.

September 12, 2002
I called Cigna today and asked them to e-mail me EXACTLY what their requirements are for wls and this is the response I got. Hope it helps! "vexxtra" Dear Ms. $%$#@$: Thank you for your inquiry about the medical necessity criteria for gastric bypass surgery. Here are some facts about how the condition is evaluated: The Body Mass Index (BMI) is an objective measurement, which is currently considered the most accurate measurement of excess adipose (fat) tissue. The National Institute of Health defines obesity as a BMI of greater than 27.5kg, and severe or morbid obesity as greater than 40kg. A comorbid condition occurs when another part of the body becomes diseased as a result of the morbid obesity. Examples include: hypertension, gastric reflux, diabetes mellitus, coronary artery disease, pulmonary dysfunction, severe sleep apnea, lower extremity venous and lymphatic obstruction, obesity related pulmonary hypertension, symptomatic osteoarthritis of the knee, hip, or back. Gastric bypass surgery is considered medically necessary and will be covered under the terms of your benefit plan if all of these criteria are met: BMI Greater than 40kg for at least five years, or Between 35-40kg with additional documentation of one or more clinically significant comorbidities that have failed to respond to non-surgical treatment, including appropriate and adequate medication. Previous Weight Loss Attempts In addition to the minimum weight requirements, you must submit documentation supporting previous weight loss attempts. The patient must have actively participated and reasonably complied in at least three professionally supervised weight loss programs for a minimum of twelve weeks in each program. At least one of these programs should have included weigh-ins on a regular basis. Age and Risk The patient must be an acceptable age and risk for surgery. This is determined by the Primary Care Physician (PCP). Comorbidities The medical records should indicate that the PCP has made efforts to treat any comorbidities using standard conservative protocols. It's important you know that the referring physician must receive pre-authorization through CIGNA's Health Services Department by submitting clinical information supporting all of the above medical necessity criteria. Please contact your PCP to discuss possible treatment plans. If the PCP feels that surgery may be necessary and that you meet the above criteria, he or she can contact the Health Services Department to start the pre-authorization process. In addition, please know CIGNA HealthCare does not guarantee or represent that any particular benefits will be paid. Payment is based on the terms of the group plan and the patient must be eligible when receiving treatment. Ms. #$@@#$, I hope this information is helpful to you. Thank you for visiting our web site. Sincerely, A. Garcia Internet Customer Service Team CIGNA HealthCare www.cigna.com Please do not respond to this e-mail ------------------------------------------------------------------------------ CONFIDENTIALITY NOTICE: If you have received this e-mail in error, please immediately notify the sender by e-mail at the address shown. This e-mail transmission may contain confidential information. This information is intended only for the use of the individual(s) or entity to whom it is intended even if addressed incorrectly. Please delete it from your files if you are not the intended recipient. Thank you for your compliance. Copyright (c) 2002 CIGNA
   — AMY P.