CIGNA really screwed up this time.....

[losinit512 12]

Hi everyone,

First off, I would like to apologize for the length of this post, but I'm at the end of my rope here and SO upset!! Second, if anyone has ever been through something like this please feel free to add your input.

Like a lot of you I've never been so motivated and excited in my life for my upcoming surgery. My husband's employer has CIGNA insurance. They have never covered bariatric surgery until what I thought was this year. In prior years they had our plan documents on their website so you were able to see the specifics of what was covered and what was excluded. We had many changes this year but for some reason they have never put this detailed information up on either the employee website or the CIGNA website this year. Needless to say, I contacted CIGNA for this information on more than one occasion. FINALLY, I received information in the mail with very detailed information saying that weight loss surgery WAS covered. Imagine my happiness!! I even contacted CIGNA via phone to verify this and it was confirmed as covered. I started all of my paperwork and submitted it to my doctor's office. The doctor's office ALSO contacted CIGNA and they were given an approval of coverage for the surgery and a reference code for the call. The requirements were for 3 months of doctor supervised weight management along with the usual psychological evaluation, high BMI, sleep apnea (check), diabetes (check), high blood pressure (check), etc. Therefore, my journey began and I stuck to the program like crazy.

I went in this past Monday for my final doctor's visit and they submitted my paperwork to CIGNA. My claim was immediately denied by CIGNA saying that weight loss surgery is not a covered benefit. If you could only see the look of despair on my face. The doctor's office informed CIGNA that my surgery is scheduled for June 23rd and that I have done absolutely everything required. CIGNA told the doctor's office that they have given the case to their supervisor and that my doctor's office would have to submit an appeal (IN WRITING, which will only slow down matters). My husband also contacted the HR benefits manager who was livid that this had happened. She informed him that they have never covered bariatric surgery and that there is NO appealing this situation.

I am having a very hard time believing that nothing can be done, especially on the part of CIGNA's more than one error. They informed my doctor's office that the employee who told them that I was approved would be reprimanded - do they honestly think that is going to make me feel any better? What about the others who sent me the information in the mail and by phone? I contacted CIGNA on Tuesday and said that they apparently have problems with training their employees. This is not something that can be brushed off as a slight error! CIGNA needs to pay for their mistakes!

One other thing of mention is that CIGNA has paid ALL of my claims regarding this preparation for the surgery, including my BARIATRIC Vitamins at 100%!! I just don't get it.

I don't know what to do with myself at this point. I am just absolutely heartbroken and numb. I've worked so hard for this and to have the rug pulled out from underneath me at the last minute is just wrong.

Thanks for reading and your understanding!

losinit512

[jeanniereenie 177]

Im sorry you are going through this, i wish i had some good advice but i dont, but i will send some positive thoughts your way and vibes hoping that it can be appealed and Cigna will make an exception considering they even got an approval code!

good luck! keep us posted!

[woo woo 872]

Go through with the written appeal process. I did with cigna after I was denied due to an error on cigna's part and was approved in a month or so after.

[Genevieve L Thompson 3]

What might've happened (as I've seen this with other people) is that yes Cigna as a whole covers the surgery (I have Cigna as well) But your husbands employer (who can elect in or out of bariatric coverage) does NOT cover it which unfortunately means that there is no appealing because if your husbands employer has elected not to cover bariatric surgery then it's not an included benefit in your personal health plan. (Your husband can speak to HR again for verification)

What the cigna employee probably did (which I'm not justifying by any means) is give you the general answer. Because the insurance does cover it but usually (and sadly) most places of employment elect out of bariatric coverage. I really am sorry about that hiccup and I pray it works out. Don't give up on your journey!

[4MRB4PHOTO 3,899]

I received a letter from CIGNA on a Saturday, the surgery was 2 weeks from that Monday, stating they would not cover the surgery due to my PCP did not document that I need the surgery and I did not go through a medically supervised diet for at least 3 months.

I contacted my PCP and surgeon. I had them resubmit the same information that was already submitted and "Abra-Cadabra" it is now suddenly approved. The funny thing is they were paying for a nutritionist and a bariatric doctor & bariatric nurses, blood work, gastro-esophageal testing, blood work, etc. at the hospital for 5 months at that point.

Get a copy of the medical plan and have your PCP and surgeon be your advocates to fight for why this is medically necessary -comorbidities and a high BMI are strong tools to sell this point.

Good luck.

Edited June 11, 2015 by 4MRB4PHOTO

[Stevehud 1,790]

i was denied by cigna, only to be okayed after appeal, and we rushed the appeal through in less than 7 days.

So it can be done, however if the employer has excepted their coverage from bariatric surgery as many employers do. there is literally nothing you can do. I eventually had to take out my own separate insurance and carry two, just to cover the after surgery items.

[losinit512 12]

Thanks, everyone. My doctor's office contacted me this morning and said that CIGNA has clearly admitted fault; however, they will not do anything about it. My husband's HR manager has said that they will not cover it. You would think that paying for this surgery would be a smart option for them considering how much they are having to shell out year after year for all of my medications. I'm just completely at a loss here. I have another call into CIGNA but am waiting for a callback. I will continue to escalate this as I cannot find a feasible excuse for their mistakes.

[ShrinkingPeach 1,291]

It is heartbreaking to get contradictory information. I agree with @@Genevieve L Thompson that they probably just looked at Cigna as a whole and did not look at your husband's specific plan. If your husband's employer did not include bariatric surgery in their specific employee plan then it unfortunately will not be covered.

When your doctors office calls in to the insurance company it is for a pre-authorization. They are assigned a number and all information sent to the insurance company is referenced to that number for record keeping and to keep it all together. The pre-authorization is not a guarantee of coverage, nor is it approval. When all documents are received by the insurance company they review the information received and compare it to your specific policy. I guess at that time they discovered that there was no coverage.

I would also be upset and frustrated but I am afraid that this will probably not be covered. I don't blame you for following through and trying but don't be surprised if that is the final answer. Maybe look at other options, perhaps a self pay price?

Good luck!

[majorsmama 91]

My husband had Cigna and his employer too, has an exclusion for bariatric coverage. It's in all the documents provided by HR. Luckily, my employers Aetna insurance does include it so I switched insurance just for the sake of having coverage. That has got to be heartbreaking and while I understand how you must feel, I agree with others who have said there is nothing you can do. Yes, Cigna got it wrong. But ultimately it is the responsibility of the insured to know their coverage. I'm so sorry.

[Sharon1964 2,530]

There is someone else on these forums who went thru the same situation. I'm not sure who their insurance carrier is. They successfully appealed citing the numerous instances of false information on the part of the insurance company.

Cigna itself can cover it. It doesn't have to affect the employer's rating or costs.

Appeal and keep appealing up the chain of command. Appeal to your state insurance commissioner if necessary.

[Sharon1964 2,530]

Here is the thread I was thinking of: http://www.bariatricpal.com/topic/334629-bcbs-carefirst-horror-story/

[losinit512 12]

Sharon1964, you are my hero. Thank you so much for posting this link!! I've been fighting with the insurance company for three days straight now and I refuse to give up hope.

Thanks again!

[momma_missie 30]

I have no advice or experience with even a similar situation.. just wanted to tell you to keep strong and keep fighting. I can't imagine the heartbreak you must be experiencing, but stay strong! I hope and pray that you are able to have surgery after all the misleading information you have received. Thoughts and prayers are with you during this struggle!

[Sharon1964 2,530]

You're so welcome. Keep up the good fight!

[losinit512 12]

After a week full of non-stop battle, Cigna has decided to make right of their error. I can't think you all enough for your comments and suggestions. You all are the best!!