CIGNA HMO, Texas

[pumpkin5 0]

I've decided that I need lapband surgery. Interestingly enough it seems that you must first decide that you want it before you know if it will be approved. Since 8/11:

• PCP Referred to a lapband surgeon. Not seen yet, because I needed my medical records released to the surgeon's office/facility where the lapband procedure will be performed.
  
• All medical records were forwarded to surgeon/medical facility on 8/16.
  
• I searched for and found a CIGNA PhD/Psychiatrist provider. Saw her on 9/1, and passed the evaluation. The report will be forwarded to my surgeon within the next 5 days if not sooner.
  
• Allowed to schedule an appointment with the surgeon/medical facility for Tuesday, 9/5. Not sure what to expect during this appointment - didn't ask because I was so excited that I was allowed to schedule one!
  
• Don't have any idea if I meet ALL of the criteria listed below. I ws told that each insurance company adheres to their own time schedule for approvals. Could be up to 4 weeks after everything has been submitted before I will know. I'm encouraged though that at least I know for a fact that my specific plan does cover the procedure.

The plan I belong to covers weight loss surgery to include lapband. CIGNA requires the following information in order to make a determination:

• Complete history & physical by the primary care physician.
  
• Psych Evaluation (PhD or Psychiatrist)
  
• Nutrition Consultation
  
• Detailed weight loss history to include documentation compliance with 1 physician directed weight loss program lasting at least 6 months and being completed within the last 6 months to include:
  • Diet therary (low calorie diet, Atkins, south Beach monitoerd by a physician)
    
  • Increased physical activity (exercise program done on a daily basis; suggested writing on a monthly calendar and giving that to your PCP to sign as reviewed and make it part of your medical record)
    
  • Behavioral therapy to reinforce dietary therapy and increased physical activity.
    
  • Consideration of pharamcotherapy with FDA-approved weight-loss drugs.

  [*]BMI >40 (without additional co-morbidities) or BMI >35 (with additional co-morbidities) such as:

  • Life threatening cardiopulmonary problems (severe obstructive sleep apnea; pickwickian syndrome; obesity related cardiomyopathy)
    
  • Type II Diabetes
    
  • Clinically unmanageable hypertension
    
  • Coronary artery disease
    
  • Obesity related pulmonary hypertension

  [*]Documented 5 year history of morbid obesity. (one chart note for each year documenting your weight is all that is required).

  [*]Must be 18 years old and/or has reached full expected skeletal growth.

Unfortunately, I think I've been eating non-stop. My current BMI is 43. Wish me luck during my appointment on Tuesday, 9/5. I think they referred to it as the medical release appointment! Anyone else with CIGNA HMO in Tarrant County, Texas, please share!

[gonnabethin 10]

Your one of the lucky ones!! LOTS dont have that.

The criteria is NOT just Cigna HMO. Most insurance companies follow the same criteria. It is this process and the waiting that drive many to Mexico self pay!! Good Luck!!

I am also lucky- after meeting and doing ALL the criteria listed I was finally approved.

[pumpkin5 0]

gonnabethin thanks! - which health insurance carrier did/do you have? How many months/years was your journey from the time you decided until you got the approval?

[gonnabethin 10]

the avg wait is 2-3 months getting all the preliminary stuff done. Its harder to try to get approval with BMI35 and co-morbidities. I had to gain to meet the 40BMI. Not something I wanted to do but 16k was not a great option either!!

[pumpkin5 0]

Still waiting - packet has not been submitted to CIGNA yet. Final items needed for the packet are coming up in the next 2 weeks.

8/9 PCP Begins Referral Process to Lap Band Surgeon

8/10 Sign PCP Medical Record Release

8/11 PCP advises referral to surgeon ready and provides me with the telephone number to call for appointment.

8/14 Darla takes intake form at Surgeon's office, someone else will call me back.

8/15 PCP Medical Records Released

9/1 Psych _Eval

9/5 Med History Review (find out I need a consultation with a nutritionist (MD) and need a stress test and heart sonogram, and blood work drawn and results).

9/5 Called to schedule the stress test and heart sonogram. Scheduled for 9/8.

9/5 Request for nutritionist referral from PCP (could take 1-5 days)

9/5 PCP calls with name of nutritionist. I call to make an appt, but can't until CIGNA approves, may take 5 days.

9/11 Nutritionist calls to advise that CIGNA approved the request. Can't be seen until 9/26.

9/5 PFT at PCP Office, and request for x-ray results

9/6 PFT Results and CXray results pick-up

9/8 Stress Test and Echo sonogram done at Cardiologist office.

9/11 Stress Test and Echo sonogram results rec'd by Surgeon.

9/113 & 9/14 check with Nutritionist for cancellations in order to get seen sooner than 9/26. No openings.

9/24 Get blood work drawn at PCP office.

9/26 Nutritional Consultation appointment scheduled.

??/?? Nutritionist consultation report?

??/?? Bloodwork results??

[pumpkin5 0]

All of my paper work was submitted yesterday at 10:00 a.m. CST. I received a call today at Noon CST from the Insurance Director at the AIGB in Richardson, advising me that I am APPROVED for surgery and fills.

Have my appointment with the surgeon on Tuesday, 10/17. I was told that surgery would most likely be scheduled a week later!!! One week of liquids.

[dolphin_dreams 0]

That's wonderful news. Congratulations.

[patty103 0]

congratulations, I was much heavier than you with a ton of comorbidities and still couldn't get it approved.

[pumpkin5 0]

Patty103 - I'm so sorry to hear that - I hope you ended up finding a way to get the WLS? I was prepared to fight the claim.

[patty103 0]

i got it just not through cigna, I had wls in june 05 and I am down 130 pounds, it was a lifesaver for me...

[pumpkin5 0]

Patty103 - that is an excellent weight loss - lots of hard work and dedication!

[Kathi 0]

I was a self pay (I had Aetna), for the lapband in April. I have been extremely frustrated with the lack of results. I know that the lapband works for some people, but it really was a waste of $$ for me. I am only down 20 pounds, and have had a dozen fills.

I just got a new job that has Cigna so when I saw this post it got me hoping that I could have a revision done to a RNY.....

Does anyone know if Cigna HMO will also cover a RNY???