Should I just self-pay?

[Daisee68 2,493]

I have Cigna. They require 3 months nutrition visits and psych evaluation. I plan to do those things anyway as I think they are important for success. Have already had Upper GI (discovered sliding hiatal hernia) and had Stress EKG today. My dr requires sleep study. She says 80% - 90% of her patients have sleep apnea and she is not comfortable doing surgery unless we are either told we don't have sleep apnea or treat the apnea with CPAP. My sleep study had been scheduled for tonight; however, insurance won't approve the sleep study. They said the clinic records did not show sufficient excessive daytime sleepiness that might indicate sleep apnea. I am sure dr. is going to appeal but it made me think, am I just going to have to have all these hassles all the way through the process? I can actually (blessedly) afford the surgery and wonder if perhaps I shouldn't just pay myself and not have to wait and jump through so many hoops. (For what it's worth, I am type II diabetic with 46 BMI.) I have a very stressful work schedule during the summer and really need to get the surgery done by early May in order to have a little time to focus on health before the worst of the stress hits or wait until October when it is all over (which I don't really want to wait for). I am worried that once my nutrition visits are completed (April 30), then Cigna won't approve or will hassle and have to go through appeals until we just land in mid-summer or later.

So, my question, should I just self-pay and skip all the mess?

[erp 2,016]

90 days is not that long. I am happy that I went through the hoops because I can get all of my aftercare in town, versus the couple of hours away the self-pay doctor I was going to use was. Keep the money for plastics. :-D

[Luvin_Life125 558]

I was very frustrated by the wait to complete all of Cigna's pre surgical requirements. It seemed like it took forever to get through it all. Now that I am post op, I am glad it took some time. It gave me time to mentally prepare, break some bad habits, and start adding positive behaviors. Cigna was pretty efficient with the pre authorization. Their policy is to issue a decision within 5 business days for inpatient surgical procedures and they met that.

You are the only one who can decide which course is best for your needs. I can say Cigna was pretty good about the pre authorization process. Make sure you read and understand Cigna medical coverage policy 0051 dated 05/15/2014. You can use the policy to ensure you complete every required step and proof of every step is collected and submitted. One item in the policy that isn't really clear is the physician monitored weight loss attempt. The policy says you need 3 consecutive months (> or = to 89 days) of physician or dietician monitored weight management program. To meet that requirement, you actually need 4 appointments because an initial appointment to start the process is required. Make sure you also schedule each appointment at least 30 days apart too. The link for the policy is https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_0051_coveragepositioncriteria_bariatric_surgery.pdf

Good luck with everything! I can't wait to see your progress and to cheer you on!

Edited February 7, 2015 by Luvin_Life125

[Daisee68 2,493]

Thanks so much for this. Knowing Cigna did finally approve you and within 5 days makes me feel much better. I was just so thrown by them not approving the sleep study. That document is really helpful! And even in there it says you need to rule out sleep apnea as part of pre-surgery requirements. Obviously my surgeon's office just didn't provide the correct info. You are both right that I need the time before to adjust anyway.

Really appreciate the advice! Feeling much calmer about it all this morning!

[woo woo 872]

I would just also add that in the very unlikely event of serious complication, you will be glad to be covered fully by the insurance since you went through them for the surgery.

Good luck. Cigna is not too difficult to deal with. They paid for my surgery 100%.

[drmeow 323]

If it's mainly the sleep study which is holding you up, why not just self-pay that part (way cheaper than the surgery itself I'm sure!) to move things along. You can always submit the claim after the fact, with documentation, esp if they do find apnea.

[Daisee68 2,493]

I was thinking the same thing about paying for the sleep study. My surgeon actually got on the phone with Cigna ND eventually they approved a home sleep study so at least we are making some progress. Looks like from other members here that Cigna does typically approve the surgery so I just have to be patient. (Not something I am great at. )

[Crosby 303]

If it's mainly the sleep study which is holding you up, why not just self-pay that part (way cheaper than the surgery itself I'm sure!) to move things along. You can always submit the claim after the fact, with documentation, esp if they do find apnea.

I agree. Why put out money you don't have to. My process has been 9 months so 3 is nothing. But I learned and prepped over this time do it has been valuable.

[blashlee 509]

90 days really isn't that long, and even if you self pay no respectable surgeon is going to operate on you without requiring at least 60-90 days of preparation (dieting, nutrition classes, EKG, lab work etc). I started seeing my doctor in January and I'll be having surgery in April. Even if I could self-pay, I would be going through all the same steps, a lot of them aren't just for insurance purposes. A good surgeon wants to make sure you're completely healthy (mind and body) to undergo the surgery because it is truly life changing.

Save your money; instead of self-paying, see what happens with your insurance. You might need that money to replace your clothes and shoes as you shrink

Edited March 1, 2015 by blashlee

[Daisee68 2,493]

FRUSTRATED - So, supposedly Cigna finally approved the sleep study - in home only - after a conversation with my surgeon. The patient coordinator tells me this 2 weeks ago but needed to "get it in writing from Cigna and find a sleep lab that does in home studies". Still no word from them so I follow up and they never got anything from Cigna and haven't followed up but will soon. I just called Cigna and they say it still isn't approved. Again, if Cigna is this difficult to just approve a sleep study and the surgeon's office isn't good in following up, it could take forever to get Cigna to approve this once I have met all the requirements. For what it's worth, I have met all the requirements except for the sleep study and the last nutritionist meeting (which by the way has been underwhelming up to now to say the least). The counselor on the other hand has been extremely helpful. I have seen her 4 times and plan to continue seeing her. So, it is not about the 90 day "diet" that makes me want to self-pay, but the mere fact that I do not want to be at Cigna's mercy and their potential stalling and then land in the busiest time of my work year and not be able to get this done until October.

[Daisee68 2,493]

I'm back. I just was reading someone's post about their surgery getting postponed unexpectedly and apparently lied to about it. in my response, I said "everything is perfect in God's timing", so I got a smack in the face that maybe there is a reason this isn't moving as fast as I want it to. I still don't like that Cigna is being so difficult but will try to patiently and calmly make sure the process moves forward.

[TMG1980TMG 136]

FRUSTRATED - So, supposedly Cigna finally approved the sleep study - in home only - after a conversation with my surgeon. The patient coordinator tells me this 2 weeks ago but needed to "get it in writing from Cigna and find a sleep lab that does in home studies". Still no word from them so I follow up and they never got anything from Cigna and haven't followed up but will soon. I just called Cigna and they say it still isn't approved. Again, if Cigna is this difficult to just approve a sleep study and the surgeon's office isn't good in following up, it could take forever to get Cigna to approve this once I have met all the requirements. For what it's worth, I have met all the requirements except for the sleep study and the last nutritionist meeting (which by the way has been underwhelming up to now to say the least). The counselor on the other hand has been extremely helpful. I have seen her 4 times and plan to continue seeing her. So, it is not about the 90 day "diet" that makes me want to self-pay, but the mere fact that I do not want to be at Cigna's mercy and their potential stalling and then land in the busiest time of my work year and not be able to get this done until October.

Any updates? Did you get your sleep study? I hope things are moving for you!

[Daisee68 2,493]

@@TMG1980TMG - Funny you should ask! I actually just got the equipment and am supposed to do the sleep study tonight. FINALLY!

[BLERDgirl 6,417]

You pay for this insurance. Why throw in the towel ? Make it work for you.

[Susan626 5]

I have Coventry of Delaware and was wondering if any one else has used this insurance to convert from band to RNY?? If so, what was your time line and what did you have to do preoperatively?
Thanks