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CIGNA Help

Night

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Night    25

Night
Posted

Prefacing this by saying I'm not sure there's any more I can do for now, but this is kind of a vent, too.

CIGNA denied me today. My surgery is December 20.

My work has a stipulation (and the insurance is through my work) that you must work there for over 1 year before insurance will cover bariatric surgery. I have been working there since July of 2015, so well over a year. My surgery nurse called me today saying CIGNA denied me because I had not been with the plan long enough.

I called my company healthcare advocacy line. The woman there called CIGNA and we had a four way conference between me, her, CIGNA rep 1, and CIGNA pre-cert rep. Both the advocate and I were vocal in saying that all of our workplace literature states 'employed for one year' and not 'had medical for over one year'. Nowhere in my benefits, on CIGNA's website, or in the calls I have previously placed to cIGNA regarding bariatric coverage has anyone said 'oh, you must be with the CIGNA plan for over one year before we will cover this'. Nowhere. I scoured everything.

So basically, the pre-cert rep said she'd send my denial back and have them re-look into it. (CIGNA rep 1 said at this point that she'd overturn the denial if it were in her power to do so, but she's low level so I can't take anything she says as even hopeful, imo...) I was told not to appeal, since my denial was going back to the pre-cert dept... but idk. I feel kind of lost. I basically have to play the waiting game to see if they are going to uphold denying me over a stipulation that is not listed anywhere. I'm incredibly grateful my company has healthcare advocates, but I was shaking with nerves by the end of the call and still am a bit.

If this surgery gets denied and pushed back... I will have to pay almost $4,000 more to have it. I won't be able to have it in January as my job will not let me have off... I won't have the hours accrued to take off enough time to recover (they reset every year). I was told they should reach a decision in 3-5 business days... My pre-op appointment is December 6. Should I call them on Monday and dog them for an update?

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Dknal2    1,066

Dknal2
Posted

Yes stay on them. I called everyday until my approval came which was 5 days. So stay on them. They usually denie everyone. Cigna is known for that but usually when you appeal they overturn miraculously. Stay optimistic .

Prefacing this by saying I'm not sure there's any more I can do for now, but this is kind of a vent, too.

CIGNA denied me today. My surgery is December 20.

My work has a stipulation (and the insurance is through my work) that you must work there for over 1 year before insurance will cover bariatric surgery. I have been working there since July of 2015, so well over a year. My surgery nurse called me today saying CIGNA denied me because I had not been with the plan long enough.

I called my company healthcare advocacy line. The woman there called CIGNA and we had a four way conference between me, her, CIGNA rep 1, and CIGNA pre-cert rep. Both the advocate and I were vocal in saying that all of our workplace literature states 'employed for one year' and not 'had medical for over one year'. Nowhere in my benefits, on CIGNA's website, or in the calls I have previously placed to cIGNA regarding bariatric coverage has anyone said 'oh, you must be with the CIGNA plan for over one year before we will cover this'. Nowhere. I scoured everything.

So basically, the pre-cert rep said she'd send my denial back and have them re-look into it. (CIGNA rep 1 said at this point that she'd overturn the denial if it were in her power to do so, but she's low level so I can't take anything she says as even hopeful, imo...) I was told not to appeal, since my denial was going back to the pre-cert dept... but idk. I feel kind of lost. I basically have to play the waiting game to see if they are going to uphold denying me over a stipulation that is not listed anywhere. I'm incredibly grateful my company has healthcare advocates, but I was shaking with nerves by the end of the call and still am a bit.

If this surgery gets denied and pushed back... I will have to pay almost $4,000 more to have it. I won't be able to have it in January as my job will not let me have off... I won't have the hours accrued to take off enough time to recover (they reset every year). I was told they should reach a decision in 3-5 business days... My pre-op appointment is December 6. Should I call them on Monday and dog them for an update?

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Night    25

Night
Posted

Yes stay on them. I called everyday until my approval came which was 5 days. So stay on them. They usually denie everyone. Cigna is known for that but usually when you appeal they overturn miraculously. Stay optimistic .

I appreciate your words!

Called them today and they have no record of me being denied. But at least it's pending medical review for necessity. And they have a note in my file that they stipulation of being with the plan for over one year does not apply to me.

Moderately hopeful!

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Who'sThere    331

Who'sThere
Posted

Yes, call!!! I had to keep on my insurance too. I have BCBS, and it's a long story, but I had to fight my surgeon's office to even submit because they ladies in the office didn't believe I would be approved despite insurance giving me the policy requirements in writing and even calling them on 3 way. They lady at my surgeon's office thought I needed to meet initial patient requirements but I'm a revision patient. In the end, my surgeon TOLD his office manager to send it.

I am a teacher and my insurance is changing in January. My main policy will be the same, but I'm losing a secondary coverage, so my out of pocket would've been really high versus none at all. Also, I am using Christmas break for recovery so I don't miss as much work. I totally understand the urgency and frustration you are going through!

Remember that you are your own advocate and don't worry about pushing them. This is a service they provide and you and your employer pay for it. Get results!

Best of luck and keep us posted!

Sent from my SAMSUNG-SM-G890A using the BariatricPal App

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Night    25

Night
Posted

So I got notice today that I was approved!

After clearing up that false stipulation (turns out being on the health plan for one year before surgery is a stipulation for a dependent or spouse - of which I'm neither!), they sent the claim back to processing. I called the Dr's office because insurance needed more clinicals. Then by this afternoon, I got notice from the Dr's office that I've been approved and we are good to go!

Apparently the surgery scheduler took it upon herself to give my insurance a big ol' call about speeding things up haha. I'm so relieved I could keel right over!

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Who'sThere    331

Who'sThere
Posted

@@Night Great news!!!

Sent from my SAMSUNG-SM-G890A using the BariatricPal App

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Dknal2    1,066

Dknal2
Posted

Congratulations night.. I was sleeved Monday and I am now in recovery process. I'm excited to see my self in 4-6 months. Good luck with everything .

So I got notice today that I was approved!

After clearing up that false stipulation (turns out being on the health plan for one year before surgery is a stipulation for a dependent or spouse - of which I'm neither!), they sent the claim back to processing. I called the Dr's office because insurance needed more clinicals. Then by this afternoon, I got notice from the Dr's office that I've been approved and we are good to go!

Apparently the surgery scheduler took it upon herself to give my insurance a big ol' call about speeding things up haha. I'm so relieved I could keel right over!

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Night    25

Night
Posted

NIGHT---did u hear back from ur ins yet?

Sent from my iPhone using the BariatricPal App

yeah I'm good to go! Dec 20th here I come c:

Sent from my SM-G530T using the BariatricPal App

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Night    25

Night
Posted

omg that is awesome! good for u! what hosp? im 19th @ Jefferson.

Sent from my iPhone

omg me too! Dec 20th w/ Dr. Kammerer (but they didn't have him as an option, so I put down Dr. Tchainsky)

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PhillyAj    90

PhillyAj
Posted

oh. i dont know either of them drs but been to they office to see the psych, NP, dietitian & kryillos lady. im seeing Palazzo. how funny is that??? lol

Sent from my iPhone

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Go To Topic Listing Insurance & Financing

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