What is considered Failure??

[sloppy joe 8]

I currenlty have Humana ins but will be moving to Cigna as of Jan 1st 2012. My company is no longer offereing Humana going forward. I decided to have WLS after a visit to my PCP when she suggested I look into it after discussing my weight.

To give full disclosure, I haven't been to a doctor in quite sometime (probably close to 10 years), I just don't go. Other than my weight I'm fairly healthy. My first visit to my PCP early Aug I asked her to run a full blood panel and do a full work up on me since I haven't been to the dr in a long time. At that first visit my blood pressure was a little high so she put me a low dose blood pressure medicine. When I came in on my second visit to review my blood work, chest xray, sonogram, everything was good. Cholestrol good, sugar level good, thyroid good, liver function good, ovaries look good, heart looks good, and lungs look good and the only comorbidity I have is lower back pain. So all in all I'm pretty healthy with a little bit of high blood pressure and lower back pain.

Also In my second visit to my PCP I disucssed my weight, I'm 5'4", 320lbs, 56 BMI and I'm 40. I'm single, never had children and been overweight all my life. My PCP recommended I look in to WLS and gave me a few surgeons to check out. She documented that visit as the start of the physician assisted weight loss management program as she knew most insurances require 6 months. Based on her recommendation I checked out the one surgeon that she recommended that was covered by Humana and went to a seminar that he held on WLS and that's when I decided on the VSG procedure. I have since had two appointments with that surgeon's office (one actually seeing the surgeon) and essentially I just need to complete my 6 months weight management program, have a psych evaluation and get a letter recommending this surgery from my PCP and submit to Humana for approval in Jan 2012.

Just last week my work announced they revised the entire medical plan and the 2012 is completely different. It looks like Cigna will be the ins that I will have starting 2012. Since I won't be completing my 6 months weight plan this year I will have to qualify with Cigna's Bariatric guildlines and here is how they state their weight management programs: "Failure of medical management including evidence of active participation within the last two years in a weight-management program that is supervised either by a physician or a registered dietician for a minimum of six months without significant gaps."

So I shared all of that to say, what is considered failure of the physican assisted weight managment program? I'm concerned that if I show weight loss and given my current health history (I'm pretty healthy, i'm just fat) that they might deny the surgery in Jan when I have completed my 6 month program. I would like to make effort during this time to lose weight to help with the surgery (about 15 -20 lbs) but I'm really concerned that Cigna will deny me the surgery stating that I didn't fail in the 6 month weight managment program since I would have lost weight. I would think that my BMI alone would be enough for the surgery even if I lost some weight during this 6 month time frame. I just don't want to ruin my chances with the surgery.

Any advice would be helpful. :-)

[Caliblonde 25]

For myself, I had to write down every diet that I have tried in the past five years, how much I lost on that diet. If you've done weight watchers, I think it might count as a monitored diet.

[ldydrgnkpr 49]

I would contact Cigna to find out what exactly their requirements are. Ask if they could send you the requirements in writing either email or snail mail. I have UHC and I called to ask what the requirements were as what was online was vague and cryptic. I spoke with a coordinator and she sent the info via email and snail mail. So I had both. The insurance coordinator with my surgeon's office even had the requirements and I received those as well. So I was aware of the requirements no hidden surprises that would delay my surgery.

Good luck

Deb

[sloppy joe 8]

I would contact Cigna to find out what exactly their requirements are. Ask if they could send you the requirements in writing either email or snail mail. I have UHC and I called to ask what the requirements were as what was online was vague and cryptic. I spoke with a coordinator and she sent the info via email and snail mail. So I had both. The insurance coordinator with my surgeon's office even had the requirements and I received those as well. So I was aware of the requirements no hidden surprises that would delay my surgery.

Good luck

Deb

When I called Cigna last week they sent me their bariatric requirements (http://db.tt/6ScLpme Link to the document) which is where I got their exact phrasing about the "failure of medical management.." Now that I have had time to read this entire document I have additional questions and will contact Cigna again with those questions.

I'm a cut and dry person and it seems like all of this is subject to interpretation.

I appreciate all the replies and suggestions. :-)

[ItsTheSleeve 2]

It sounds like the "supervised" diet you are doing with your primary will cover you. It is within the last two years. I wouldn't lose too much weight during that time because like you said you don't want them to deny you because you were able to do it on your own. However, 15-20 pounds is not going to dramatically change your BMI. Good luck and I hope everything works out for you with CIGNA.

[pattimomof3nj 21]

Maybe it means failure to complete the 6 months of medically supervised diet. Like if you start then stop and start again 3 months later. You know what I'm getting at here. Like if you are a habitual re-starter, someone that has a slight gain, quits, then restarts, gains, quits starts again. That is a waist of their time and resources and someone that is not going to take WLS seriously and will be a failure in their book.

At least that is my interpretation of it. I got lucky, I started my 6 months and my work changed insurance company, then I didn't have to do it, 2 months into it, go my lap band the next month!

Good luck!

Patti

[Tai29 17]

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.