Jump to content
×
Are you looking for the BariatricPal Store? Go now!

So Upset.......please Need Advice And Input!



Recommended Posts

I was planning on introducing myself.... and so happy to tell everyone that my surgery date is set for Oct 8. I have done the six month supervised diet,all the preop tests everything that was required. I came home tonight and received a letter from Cigna stating at this time they do not feel there is medical necessity for this surgery and that I should send more documentation to support the necessity. I am 275 lbs 5'3,my BMI is 50 ....Really...my knees hurt,Im tired all the time,my back,feet hurt etc and oh yeah I want to live longer,be healthier,see my kids grow..Im so ready in every sense of the word for this.I have a bad feeling.I do not have diabetes or high blood pressure,so if a BMI of 50

being 275 lbs at 5'3 is not enough and not having any comorbitities (sp) Im not sure what I can do.I feel like Im going to have a fight on my hands.I mean the good news is it said this is not a denial letter,but I am just not sure what more I can send them to warrant the surgery. Please any advice is welcomed I wanna so bad join all of you on that loosers bench. I get so inspired and excited reading all of your stories on here.

Share this post


Link to post
Share on other sites

Do not give up. They may need proof that you have been obese for the last three or four years. Speak with your bariatric surgeon's office and see what their take is on it and maybe they can help. Are you pre diabetic? Hemoglobin A1C of 5.7 and up? That can help your cause, if so. Good luck to you.

Share this post


Link to post
Share on other sites

I know someone who drank a coke before her fasting lab work so it would look like she was a diabetic. That's what ultimately led to her doctor approving her surgery. She was 5'4" and over 300 lbs and furious that she had to do that to get approval, but it worked for her.

Sorry you are having to deal with insurance. Perhaps your doctor could provide another letter explaining the rationale for the need for surgery. Good luck to you.

Share this post


Link to post
Share on other sites

In have read in more than a few places that CIGNA automatically declines the firsttime and you have to resubmit it then it will go through. Have you had a sleep study? Having a CPAP machine would count as a comorbidity. Your leg and back pain should count too. Not even a little high BP? What about cholesterol? That counts. do not give up!! You will get there.

Share this post


Link to post
Share on other sites

Have you been tested for sleep apnea?

Share this post


Link to post
Share on other sites

Hi Ginger,

Please do not get down, I exactly how you feel as I spent the last year arguing with my insurance company. Be determined and most importantly know that you surgeon will help you in any way possible. I have a top bariatric surgeon from Boston Mass. and even with her help it took this long. Here is a lsit of all I have been through so you can see how horible these companies can get:

  • had lapband out 4/2011 because it infected and almost killed me
  • 9/2011- Surgeon submitte for revision and we were denied because they wanted updated info.
  • 12/2011-was denied because BMI was not high enough and I was not sick enough(truely this is the honest truth)
  • 2/2012-denied again still not heavy enough(gain40 lbs. at this point)
  • 4/2012-BMI finally right, new medical info. submitted was denied again..why the company never updated any info that ahd been sent. Denial based on info. fro, 9/2011
  • 5/2012-had outside appeal and talked with lawyer
  • 7/2012-re-submitted thing outside appeal wanted was denied again(this time because they again did not us new information and BC/BS even had infor. that was not mine in this denial
  • 8/2012-Surgeon had enough called BC?BS and informed them their info. was not anywhere near correct...after this coversation..surgery was approved and done last Tuesday.

This no doubt the worst part but be strong and you will make it. Most importantly keep ALL information from the insurance company and the info. sent to them. By proving they were not being honest and doing their job they could no longer deny because I had all the info. to prove I meant all credentials they required. The icing on this cake is BC/BS refused to return the hospitals calls for approvals I had to fax them down today.

As you can see this last year was hell but like me you will come out on the other side, just do not quit. Determination ticks of the insurance companies and really will pay off. Hope this helps.

Share this post


Link to post
Share on other sites

It wasn't an outright denial, so they're looking for info. As the previous posters said, get with your surgeon's insurance coordinator, and they should be able to tell you what can help your case. That's what they specialize in, getting insurance to pay. With a high BMI, even without co-morbidities, I'm sure there's something that can be used. Fatty liver disease? High cholesterol? Borderline diabetes? Joint pain? Back problems? Pre-hypertension? You have to get creative. Good Luck!

Share this post


Link to post
Share on other sites

Most good bariatric centers know which hoops they have to jump through for which insurances. Talk to the coordinator there.

Share this post


Link to post
Share on other sites

http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0051_coveragepositioncriteria_bariatric_surgery.pdf

According to CIGNA's medical policy, a BMI of over 40 is all you need to qualify as long as you have done the other hoop jumping. I am guessing this is a paperwork error and an appeal from the surgeon will fix it.

I know it may not seem like it, but insurance companies don't really try to disqualify as many procedures as they can as a rule. They are one of the most heavily regulated industries in the USA. Because of this, most of them employ more lawyers than doctors- that's where all the red tape comes from.

Share this post


Link to post
Share on other sites

It is true that big hospital's do have insurance coordinators, but what is not mentioned is when your partial denied, need more info. or outright denied the patient has to initial all appeals. The hospital will get the info. but my case proves even with the doctors doing the right thing, a patient still their own best line of defense.

Share this post


Link to post
Share on other sites

In reply to Geno....though many believe as you do that the insurance companies have these regulations, that in my case is not true. BC/BS in NH is considered a private insurance for my husband's company...they answer to no one even the government. I was beyond shocked when I found this out. This nasty little secret is the reason many companies can get away with their crap.

Share this post


Link to post
Share on other sites

All insurance carriers fall under some type & extent of state & federal regulation. That said, if the policy & claims are paid for by the employer, they can do a lot more with what they say is approved or not.

Ginger, Geno is right, file an appeal (most want it in writing) and then get in touch with the insurance coordinator at the surgeon's office. If they don't know, call your customer service number, write down the name of everyone (dates & time) of who you talk to. Ask for a supervisor & ask what you need to qualify. Most will tell you!

Share this post


Link to post
Share on other sites

I to thought this was true but it is not. in NH the BC I deal with does not have to answer to the state or fed. governmemt. I know you may well disagree but having just fought this battle and having a fed. government employee call me and tell me this information I was shocked. So as sad as it maybe, believe it or not....all insurance companies do not ahve to answer to anyone but themselves. Please look this up and you will see that it is indeed another sad state of affairs with insurance companies and having been told i first needed more info. an was then was turned down, I felt she should not the worst as I have just been through it.

On a lighter note, I noticed our surgery date was the same congrats and I to just had my first appt, and I have also lost 10lbs.

Share this post


Link to post
Share on other sites

I to thought this was true but it is not. in NH the BC I deal with does not have to answer to the state or fed. governmemt. I know you may well disagree but having just fought this battle and having a fed. government employee call me and tell me this information I was shocked. So as sad as it maybe' date=' believe it or not....all insurance companies do not ahve to answer to anyone but themselves. Please look this up and you will see that it is indeed another sad state of affairs with insurance companies and having been told i first needed more info. an was then was turned down, I felt she should not the worst as I have just been through it.

On a lighter note, I noticed our surgery date was the same congrats and I to just had my first appt, and I have also lost 10lbs.[/quote']

I am going to have to respectfully disagree. I have worked for health insurance carriers for nearly 20 years and even at the lowest form of regulation--they must be licensed to sell policies.

Share this post


Link to post
Share on other sites

That is fine..we all have our differences, I know what I have just been through and actually have paperwork to prove what I am saying. You actually can call the NH State Board of Insurance and they will tell you that Anthem BC/BS of NH maybe liscenced but are not regulated.

This was not meant to cause disagreements but to try and helper understand that no matter the reasons, do not let the insurance company make you feel like giving up. Bottom we are all here to help each other through the struggles tears and anger we feel when insurnace companies turn our worlds upside down. Would you not agree?

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Trending Products

  • Trending Topics

  • Recent Status Updates

    • vsg.with.sharon

      Hey everyone!
      I’m new here! Looking for some friends! 🥰
      · 0 replies
      1. This update has no replies.
    • LeighaTR

      Four days post surgery. I am sipping as fast as I can and getting NO WHERE near the goal of 60 - 80 grams of protein or the 64 oz of liquids. I just feel FULL. I don't know if it can still be the gas build up (I would think by now that would be gone) but it is a struggle to drink. And so far I have not had the nausea or spasms and don't want to wander into that territory by pushing too hard with liquids. I about passed out today as it was my most "strenuous" day. Went from second story to basement for shower and I was sure I was going to pass out. Looking back on my last few days I have had a total of less than 1000 calories. Am I just not getting enough nourishment in me? Once again a friday where I can't get ahold of the doc until Monday rolls back around so I am hoping maybe someone here has some experience on how to keep energy going. I do have fibromyalgia too and that may be where some added fatigue comes into play. How did you all fair with the goals the week after surgery?
      · 0 replies
      1. This update has no replies.
    • Doughgurl

      2 days until I fly out to San Diego to have my Bypass Surg. in Tiajuana Mexico. Not gonna lie, the nerves are starting to surface. I don't fear the surgery itself, or the fact that I'm traveling alone, but its the aftermath that I'm stressing about the most, after this 8 week wait. I'm excited to finally be here, but I am really dreading the post surgical chapter. I know its going to be tough, real tough and I think I'm just in my head to much now that the day i here. Wish me luck, Hopefully I'm one of the lucky ones, and everything goes smoothly. Cant wait to give an exciting update,. If there is anyone else have a June bypass or even a recent one, Id love to have someone to compare war stories with. Also, anyone near San Antonio Tx? See ya soon with the future me. 💜
      · 3 replies
      1. Phil Penn

        Good Luck this procedure is well worth it I am down to 249.6 lb please continue with the process..

      2. Selina333

        I'm in Houston so kind of near you and had the sleeve in Dec. Down 61 lbs. Feeling better. Was definitely worth it. I hope the everything is going well for you. Update us when you can!

      3. Doughgurl

        I am back home after my bypass surgery in Tiajuana. I'm post op day 4. Everything went great! I guess I'm one of the lucky ones who have not encountered much pain at all, no nausea thus far and I'm having no problem keeping down broths and water. Thank you for your well wishes. I cant wait to keep up this journey and have a chance at better health and simply better quality of life. I know there will be bumps in the road ahead, and everything won't be peaches and cream, but at least I have a great start so far. 😍

    • LeighaTR

      I am new here today... and only two weeks out from my sleeve surgery on the 23rd. I am amazed I have kept my calories down to 467 today so far... that leaves me almost 750 left for dinner and maybe a snack. This is going to be tough for two weeks... but I have to believe I can do it!
      · 0 replies
      1. This update has no replies.
    • Doughgurl

      Hey everyone. I'm new here so I thought I should introduce myself. I am 53y/o and am scheduled for Gastric Bypass on June 25th, 2025. I'm located in San Antonio, Texas. I will be having my surgery in Tiajuana Mexico. I've wanted this for years, but I always had insurance where bariatric procedures were excluded. Finally I am able to afford to pay out of pocket.  I can't wait to get started, and I hope I'm prepared for the initial period of "hell". I know what I have signed up for, but I'm sure the good to come will out way the temporary period of discomfort and feelings of regret. I'd love to find people to talk to who have been through the same procedure or experience before. So I look forward to meeting you all. Hope you have a great week!
      · 2 replies
      1. Selina333

        I'm so happy for you! You are about to change your life. I was so glad to get the sleeve done in Dec. I didn't have feelings of regret overall. And I'm down almost 60 lbs. I do feel a little sad at restaurants. I can barely eat half a kid's meal. I get adults meals often because kid ones don't have the same offerings at times. Then I feel obligated to eat on that until it's gone and that can be days. So the restaurant thing isn't great for me. All the rest is fine by me! I love feeling full with very little. I do wish I could drink when eating. And will sip at the end. Just a strong habit to stop. But I'm working on it! You will do fine! Just keep focused on your desire to be different. Not better or worse. But different. I am happy both ways but my low back doesn't like me that heavy. So I listened (also my feet!). LOL! Update us on your journey! I'm not far from you. I'm in Houston. Good luck and I hope it all goes smoothly! Would love to see pics of the town you go to for this. I've never been there. Neat you will be traveling for this! Enjoy the journey. Take it one day at a time. Sometimes a few hours at a time. Follow all recommendations as best you can. 💗

      2. Doughgurl

        Thank you so much for your well wishes. I am hoping that everything goes easy for me as well. We don't eat out much as it is, so it wont be too bad in that department. Thankfully. Also, I hear you regarding your back and feet!! I'd like to add knees to the list. Killing me as we speak! I'm only 5' so the weight has to go. Too short to carry all this weight. Menopause really did a doosey on me. (😶lol) My daughter also lives in Houston. with her Husband and my 5 grand-littles. I grew up in Beaumont, so I know Houston well, I will be sure to keep in touch and update you on my journey. I may need some advice in the future, or just motivation. Thank You so much for reaching out, I was hoping to connect with someone in the community. I really appreciate it. 💜

  • Recent Topics

  • Hot Products

  • Sign Up For
    Our Newsletter

    Follow us for the latest news
    and special product offers!
  • Together, we have lost...
      lbs

    PatchAid Vitamin Patches

    ×