Tai29

I can't see how this can become a "trend". My insurance company had some of the easiest qualifications to meet, and even they wanted to see 5 year weights and dates. So basically you have to have been 100 lbs overweight for a minimum of 5 years before they even consider you eligible and they want medical records from physician's within the past 5 years to prove it.

@ Njjewing Did Aetna say why this was denied? Were the CPT codes submitted to preauthorize the sleeve the same codes submitted during billing? Sometimes we have issues with precertification stating it was never obtained due to an insurance compang internal system issues not attaching the authorization number automatically to the member file and/or claim. It's best to get involved and find out the exact denial reason to know the next steps you need to take to have them reconsider the charges.

Dreyonalds, I am told that a week should be suitable. You have to make sure you are slowly and surely incorporating excersize in when you can. I have been told this helps with speedy recovery- getting as active as you can, as soon as you can but keepin in mind not to overdo it.

I totally agree yet still find it weird how much attention your coworkers pay you and you don't even notice. I can't tell you what my coworkers are wearing 3 min after they're out of sight but some of the hens in my office can tell you EVERYTHING about ANYONE!

You were a cutie before, but you're a bonafied post op HOTTIE! Congrats on your success. Here's to a healthy, happy life!

I took a look at the guidelines you have a link for and OH MY.. It seems like they want to discourage members from having this with all the hurdles they want you to jump through. I am really very lucky that my husband's insurance only required me to obtain "weights and dates" for the past five years. Which consisted of me calling my PCP and just asking him to write down my weight for each physicial I had from 2007 until current. Anyway... to answer your question: You should have a BMI of 40 or greater, if your BMI is 35 - 39.99 you must have a CLINICALLY SIGNIFICANT comorbidity which would be sleep apnea, hypertension, diabetes, heart disease, hyperlipidemia. .. something along those lines - and the low back pain would not be a qualifying comorbidity. Then, failure of a medical management of obesity would include: physician monitored diet and exercise plans, counseling, and medication therapy (some drugs like Topomax will cause decreased hunger/ loss of appetite) or any other prescribed weight loss drugs. They require that you provide evidence of active participation of any of the above therapies/treatements within the past 2 years. Your weight program HAS to be supervised by a physican or registered dietician. for a MINIMUM of 6 months, with no gaps during that time period. Also the catch to this is any weight loss programs that have included the use of pharmacologic management (weight loss medication) is not acceptable. They also require a seperate evaluation by a physician who is not related to the surgery to give you a clean bill of health, stating you are fit enough to have surgery. Then the bariatric surgeon has to submit a pre-determination letter or treatment plan where he will list the CPT codes for the exact surgery you're having and include your diagnosis of morbid obseity as well as any other comorbitiesThen they require the customary evaluations by a physchiatrist, registered nutrionist/dietician. I also noticed that Jenny Craig, Weight Watchers are okay to them but it has to be supervised and documented. However, if you have "long-standing" morbid obesity they will accept participation in some of the above plans under physcian supervision that lasted for a minimum of 6 months if you did it within the last 5 years. I hope this is helpful information. I decipher insurance jargon on a daily basis for our patients.

I don't know why this appears as all asteriks but included in the description of plan types was H-M-O for Health Maintanence Organization.. cmon VST!

It's ALWAYS ALWAYS best to check with the insurance company first. The type of plan you have may differ from others depending on if this is employer/group or individual coverage. Also depending on which type of Cigna plan type/product (***, PPO, POS) you have. With that being said, what I have run into the most with Cigna is they want your BMI to be at least 40 OR a BMI 35-39.9 with a comorbidity such as sleep apnea, diabetes, or hypertension just to name a few. Your surgeon's office should submit a treatment plan, or pre-determination letter to Cigna including CPT and diagnosis codes to further guage if Cigna will consider you eligible for this procedure. I hope this helps. :-)

Thanks everyone for all the replies. You all don't know how much of a relief it is to hear these things. I think I have heard so many negative stories about recovery that it has frightened me into thinking I will be completely incapacitated for 4 or more weeks. That would be horrible for a busy body like myself. Again thanks a million for the replies and such. Looking forward to being able to contribute to post-op knowledge forums myself!

Tippy Thanks..that is great advice. I think I will do just that. Hope for the best & that I am well enough to return in 7 days and upon my return work half days for another week or so.

It's really not that simple. In the grand scheme of things a preapproval does not mean anything. It only means that your insurance company has reviewed the guidelines for which a person can have that surgery, and the diagnosis codes, etc that your surgeon's office submitted to them are all in line with industry standards for that surgery. There are a million things that can happen once they recieve the claim which will disqualify payment. The most popular being the employer group no longer wants to cover this type of procedure for it's enrollee's. It may be a popular procedure, and the costs the company (employer) are incurring are more than what they want to pay, so they remove it from their list of covered services. A pre-approval is not a guarantee of payment and that verbage in some way or another is actually on your pre-approval letter. If it were this simple, I'm sure he would have done this already - and actually I do recall reading near the beginning of the thread where he did call, and was told they would reprocess and that got him nowhere. The best thing to do in this case is go to HR. If it's not covered anymore, and this is insurance through his work - their benefits office would determine what services are covered or not. I actually had a company pay their members surgery costs last week because the same thing happened to a patient who received surgery at our hospital. Most employer's are not this willing to ammend their mistakes like this though.

Working for a hospital that is also a premier bariatrice center of excellence, I see this all the time. BCBS is a main offender. As the patient, I will reccomend that you stay on top of them because they quite frequently say they will reprocess something and it will go into the Anthem black hole and when you follow up you will learn they really have done nothing with the claim. Also, I would suggest finding out WHY they denied the claim. It is also important to note, the pre-approval is not a guarantee of payment. The insurance company determines payment eligibility upon receipt of claim, and surgery notes, etc. They are under no obligation to pay for your medical services because you received a preapproval letter. Frequently we will receive precertification for inpatient hospital stays, only to have them denied once we submit the claim. We end up going through appeals processes to overturn their original denials. Insurance companies are very ambiguous in their wording so that if they do decide to deny something, they can site the technicality in the letters to you that will allow them to not do so. Also, what someone else said is true too - your benefits are ultimately determined by your group (employer). Companies buy insurance packages that are one size fits all, and they in turn distrubute them to their employees. The company you work for determines what they would like included in the benefits package and sometimes costly procedures are nixed for budget purposes.

Thanks so much for your reply!! I do work for a very busy hospital but fortunately for me, I work in billing so my job is sedimentary. Your reply gives me hope that maybe I can have a speedy recovery too! Thanks a bunch!

I had been trying to think of how to work this out myself. Unfortunately for me, in my area I work for one of the most popular hospitals and the surgeon I am using also works for this hospital. Soooo my claim is bound to come across one of the billers desks and all they need to see is this doctor's name with the V code for obsesity and they will know. And of course they're not supposed to disclose my information like that due to HIPAA, but they will ... so in my case I have just just I told my immediate management and left it at that and stopped stressing about it. This is supposed to be a happy time where I can finally look forward to acheiving personal health goals. Besides, I figured a lot of people will put two and two together when I start loosing a lot of weight rather quickly.

Hello All, I'm new to the forum and in the beginning stages of preparing for surgery. The biggest hurdle is over though, as my insurance has approved the surgery (it took them 24 hrs!) and now I find myself putting off my consult with the surgeon because during this time he likes to talk about suregry dates and I am just unsure as to when I should have it done. My deciding factor for a surgery date will be based on how long it takes to recooperate. So, if you would all be so kind as to share your post-op recovery timeframes and stories I would greatly appreciate it!