Cigna (Recent Apporval)

[Add512 2]

I had my surgical consultation today for revision, but on the off chance that it is not deemed medically necessary for revision, I do qualify for bariatric surgery in general, repeating all of the requirements as if it were a new procedure. My question is regarding Cigna coverage. Most plans require a monitored 3, 6 or 12 month diet/nutrition/weight loss management through PCP or somewhere similar. Cigna's policy says NOTHING about this, only that "a statement from a physician other than the surgeon, that the individual has failed previous attempts to achieve and maintain weight loss by medical management" - it gives no other requirements or indicators. I called Cigna today to inquire and they couldn't tell me anything more about this.

So, for those of you that have been approved in the past few months (Cigna's policy requirements look to be effective 10/9/18 through 7/15/19), what did you provide for this? I have to have a letter from my primary anyway that recommends bariatric surgery. Would this be the same letter or separate? And what did you submit/have your PCP write to say that you had failed previous attempts? Thanks in advance for your help!

Edited March 4, 2019 by Add512

[ladykrisgraff 14]

I just had my surgery on the 21st, and I went through Cigna.

My doctor handled all of the preliminaries, I'll admit, but I was going through the bariatric surgeon to begin with, and he knew what they needed. I will say this, Cigna only required a 3-month medically assisted weight loss (I went through my endocrinologist) in which I could show that I was losing weight, if only a pound, between visits. It was tough. My doctor also had me go though a lot more, which I don't know if they were requirements for the insurance or his MO. I had to undergo a sleep study, a psych evaluation, an endoscopy, a visit with a nutritionist, a whole round of bloodwork and pap smear, mammogram, and clearance from a cardiologist.

Not sure if this helps or not, but I'm sure that if you call some bariatric surgeons in your area, they'll be able to check for you. I know mine has a couple of women dedicated just to insurance verification/communication. My advice is to let someone who knows what the insurance companies typically ask for and who has experience in dealing with them do the legwork if you can. If there is no one nearby, maybe go to someone in a bigger city nearby. (I was fortunate enough to already live in a big city, so I didn't have to do much digging.)

I hope all of this helps. Let me know if you need anything else from me.

I wish you the best! ❤️

[KarenLR75 518]

On 3/4/2019 at 3:06 PM, Add512 said:

I had my surgical consultation today for revision, but on the off chance that it is not deemed medically necessary for revision, I do qualify for bariatric surgery in general, repeating all of the requirements as if it were a new procedure. My question is regarding Cigna coverage. Most plans require a monitored 3, 6 or 12 month diet/nutrition/weight loss management through PCP or somewhere similar. Cigna's policy says NOTHING about this, only that "a statement from a physician other than the surgeon, that the individual has failed previous attempts to achieve and maintain weight loss by medical management" - it gives no other requirements or indicators. I called Cigna today to inquire and they couldn't tell me anything more about this.

So, for those of you that have been approved in the past few months (Cigna's policy requirements look to be effective 10/9/18 through 7/15/19), what did you provide for this? I have to have a letter from my primary anyway that recommends bariatric surgery. Would this be the same letter or separate? And what did you submit/have your PCP write to say that you had failed previous attempts? Thanks in advance for your help!

This! This is what I found when I was trying to 'check off' that I met all the requirements and yet at my appt with my bariatric surgeon yesterday they said CIGNA REQUIRED SIX MONTHS OF BACK TO BACK VISITS WITH A NUTRITIONIST and they MUST be sequential back to back visits or you start over!!!???? I have a year of supervised medical weight loss with my primary dr, a BMI of over 50, pysch eval clearance letter, even letters from other dr's like ortho's who said my knees must be replaced but I need to be at a BMI of 40....and yet I was told that Cigna didn't care about the supervised weight loss. They want me to meet with a nutritionist for SIX MONTHS to do WHAT? I AGREE I need to see a nutritionist although nutrition was always the topic of discussion with primary dr.....but for SIX MONTHS? That's a more rigid requirement than the weight loss and I worked on the weight loss for a year as I wanted to be very sure of things.

Why do we get so many different answers..I have Cigna 90/10 plan (I pay extra for higher coverage as I usually am in hospital for 2 weeks every other year...why keep paying a 50K to 100K hospitalization bill for me when we can treat SOME of the underlying reasons and keep me OUT of the hospital?).

I'm afraid to even call them. My bariatric surgeon is experienced...not sure about his staff as I just met them and he is building out a new office so they are co-sharing office space with an OB-GYN (like that wasn't uncomfortable)...should I call CIGNA myself or let dr handle? I really am now feeling leery of his staff

[Add512 2]

So. I am still in the middle of this process. My surgeon's office is also telling me i have a 6 month nutrition visits, but I've spoken to cigna THREE times in the past two months, and they have continually assured me that the specifications i've been given (above) are correct, and there's no 6 month requirement. my surgeon's office basically said that they'd submit the paperwork and we'd see what happens. I figure if they deny and we have to appeal, it's pretty obvious that the plan does not outline that this is a requirement. the only thing that says 6 months is that we have to have all of the requirements done within a 6 month period. the insurance coordinator at my surgeon's office is adamant about the 6 month thing, but i've spoken to a few people on bariatric forums that have said their cigna also did not have the requirement, so between that and my talking to cigna multiple times, i feel OK (but not 100%) about being approved. I will let you know once I find out, I'm guessing it'll take a week or two to get an answer back from them. My theory is that if cigna wants me to meet with a nutritionist for 6 months it should be clearly listed in the bariatric surgery requirements for my plan. it is not. and they have confirmed. sigh. i feel you. i would suggest that you call cigna, they will tell you the same thing as i just did, and then tell your office that you've spoken to them.

[KarenLR75 518]

Just got off phone with CIGNA. They reviewed MY specific coverage and stated that this Is NOT one of their requirements.

We stepped through ALL of the requirements for their current policy which is effective thru 7/15/19.

I have a downloaded copy of the specific and current policy regarding bariatric surgery. The CIGNA rep on the phone was mystified as to how the dr's office feels that the 'six months with a nutritionist' is a requirement.

I called Dr. Dyslin's office staff back and was chided a bit for 'calling the insurance' which honestly upsets me. The young lady was nice but she is NOT proficient with reading/understanding medical verbiage and what it means. She said she and her office manager are confused YET they are looking at the same policy (policy 0051 for me) and they don't understand IT!!!! Said they will call insurance to check again but advised that I NOT CALL the insurance to 'get things confused'!! CONFUSED??!! I've been studying this for four years and since I am end up hospitalized every other years for the past several years I've become very INSURANCE PROFICIENT.

I like Dr. Dyslin but if his staff is so GREEN they can't interpret to me what is CLEAR AS DAY to both myself AND CIGNA....I'm a bit concerned I may need a different office..and I really liked the doc!!

HERE is the part they are hung up on which CIGNA said doesn't mean 6 back to back meetings with a nutritionist and I AGREE

A thorough multidisciplinary evaluation within the previous six months which includes ALL of the following: 

a description of the proposed procedure(s) 

a separate medical evaluation and/or a recommendation for bariatric surgery from a physician/ physician’s assistant/nurse practitioner other than the requesting surgeon or associated staff 

unequivocal clearance for bariatric surgery by a mental health provider 

a nutritional evaluation by a physician or registered dietician

[KarenLR75 518]

41 minutes ago, Add512 said:

So. I am still in the middle of this process. My surgeon's office is also telling me i have a 6 month nutrition visits, but I've spoken to cigna THREE times in the past two months, and they have continually assured me that the specifications i've been given (above) are correct, and there's no 6 month requirement. my surgeon's office basically said that they'd submit the paperwork and we'd see what happens. I figure if they deny and we have to appeal, it's pretty obvious that the plan does not outline that this is a requirement. the only thing that says 6 months is that we have to have all of the requirements done within a 6 month period. the insurance coordinator at my surgeon's office is adamant about the 6 month thing, but i've spoken to a few people on bariatric forums that have said their cigna also did not have the requirement, so between that and my talking to cigna multiple times, i feel OK (but not 100%) about being approved. I will let you know once I find out, I'm guessing it'll take a week or two to get an answer back from them. My theory is that if cigna wants me to meet with a nutritionist for 6 months it should be clearly listed in the bariatric surgery requirements for my plan. it is not. and they have confirmed. sigh. i feel you. i would suggest that you call cigna, they will tell you the same thing as i just did, and then tell your office that you've spoken to them.

You ABSOLUTELY NAILED IT. I posted before I saw your reply. WHERE/HOW/WHY ARE our dr's offices coming up with this requirement when it is NOWHERE IN THE POLICY AND CIGNA THEMSELVES SAYS "WE DO NOT REQUIRE THAT?". You don't happen to be in Texas as well do you? Honestly, going thru the policy with my dr's office person was PAINFUL. She was having trouble understanding what the 'WITHIN' 6 months part even meant.

Then was told I shouldn't call...i shouldn't what??? If THEY Are confused, I HAVE TO CALL. Still mystified as to how both of our doctor's office are hung up on something that is NOWHERE in the stated policy which for me is policy 0051 which is currently in effect from 10/9/2018 to 7/15/2019. STUMPED BEYOND BELIEF. I thought it was usually a fight with insurance NOT with the doctor's staff!!!

Medical Coverage Policy: 0051

Effective Date: 10/9/2018 Next Review Date:7/15/2019

Coverage Policy Number: 0051

[Add512 2]

I'm in MD and my policy is in NJ but it's the same as your policy. I'm not sure why my office thinks this is also a requirement but they at least relented and said they'd turn in my paperwork to see if it would go through. I do trust that they do this regularly and have a lot of experience dealing with it but I can read and have confirmed numerous times. They said they called and talked to cigna too and confirmed but i'm thinking someone didn't do that. Either way, I'm glad to hear I'm not the only person that is getting this weird issue.

Weird that they told you not to call. it's your insurance, you can call them whenever you want

[Add512 2]

I will say that I believe Cigna having some policies without this requirement is new as of last year. Some also still have 3, 4 and 6 month requirements but not our policy (I specifically picked it knowing I was having revisional surgery and that it would give me the best coverage) and I don't think, at least with my surgeon's office, that they've had any roll in yet. I dunno haha. I'll let you know what I find out about my surgery being approved so you can at least have some additional ammo or information!

[KarenLR75 518]

OMG...the dr's office called back and said they called CIGNA and were told that I had to do the 6 months, ,consecutive, yada, yada, yada and this is why it is best to 'let them handle these things' as I don't know the right people to 'talk to'.

EXCUSE ME? I don't know the right ppl to talk to? I didn't call for 'basic coverage'. I called for the legally binding policy COVERING what their REQUIREMENTS ARE. Like you, I think/feel that these people should be very experienced with making these calls but the way she tried to read back policy 0051, I could tell she was very very very very confused!

And she's saying to cancel the appt with the nutritionist for this month and 'just go' next month. She wants me to go back to my primary and get more 'notes' even though he wrote a letter detailing everything!

I SO do not want to have a bad relationship with my doctor's staff! I never want anything like this. I just DO NOT BELIEVE this one person is truly comprehending how crazy all of this is..not even saying 'hey, this doesn't make sense...we should be hearing the same thing...let's do a conference call (which I suggested). I feel like I'm alienating them and I'm just at my wit's end here.

I also feel bad for them and us as this is obviously something VERY VERY STRANGE related to CIGNA so we are all having to go through extra struggle and frustration because BOTH of us have had this same..."interpretation issue".

I can't wait to hear how yours goes! I'm rooting for you. I also need to think how to...let my dr's office know..this is NOT personal and I'm not trying to argue. I am genuinely confused and I have dealt with Cigna so much in the past decade plus I work in a software industry that deals with healthcare, insurance..so I'm not a complete newbie.

Am worried they now think I'm some desperate person that doesn't want to do what is required. All I have ever wanted to do was 1) Do what was required but more importantly 2) ensure that this decision was right for me and that I was 'right' for it. Right as in ready. Right in my head space, right in my willingness to work hard, right to meet and EXCEED the requirements from CIGNA as this was not an easy decision and I"ve spent 4 yrs exploring all options and am at peace with the work I've put in, where I'm at emotionally and mentally and the agreement and research with other specialists and doctors I've seen.

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KarenLR75

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Posted just now

Just got off phone with CIGNA. They reviewed MY specific coverage and stated that this Is NOT one of their requirements.

We stepped through ALL of the requirements for their current policy which is effective thru 7/15/19.

I have a downloaded copy of the specific and current policy regarding bariatric surgery. The CIGNA rep on the phone was mystified as to how the dr's office feels that the 'six months with a nutritionist' is a requirement.

I called Dr. Dyslin's office staff back and was chided a bit for 'calling the insurance' which honestly upsets me. The young lady was nice but she is NOT proficient with reading/understanding medical verbiage and what it means. She said she and her office manager are confused YET they are looking at the same policy (policy 0051 for me) and they don't understand IT!!!! Said they will call insurance to check again but advised that I NOT CALL the insurance to 'get things confused'!! CONFUSED??!! I've been studying this for four years and since I am end up hospitalized every other years for the past several years I've become very INSURANCE PROFICIENT.

I like Dr. Dyslin but if his staff is so GREEN they can't interpret to me what is CLEAR AS DAY to both myself AND CIGNA....I'm a bit concerned I may need a different office..and I really liked the doc!!

HERE is the part they are hung up on which CIGNA said doesn't mean 6 back to back meetings with a nutritionist and I AGREE

A thorough multidisciplinary evaluation within the previous six months which includes ALL of the following: 

a description of the proposed procedure(s) 

a separate medical evaluation and/or a recommendation for bariatric surgery from a physician/ physician’s assistant/nurse practitioner other than the requesting surgeon or associated staff 

unequivocal clearance for bariatric surgery by a mental health provider 

a nutritional evaluation by a physician or registered dietician

surgery

[Add512 2]

FYI Cigna sent my approval today so we are correct on the no 6 month thing for our plans. :)

[KarenLR75 518]

oh my gosh, I'm SO HAPPY for you!! Congrats!! I'm not even sure I can get my dr's office to go ahead and submit. The young lady who is giving me the hardest time said "I spent 2 hrs on the phone with them just to make sure and they said it had to be 6 months, back to back..yada, yada, yada"

She makes me VERY CONCERNED in that she never wants me to be part of the convo with my own insurance and always says that me calling makes things harder as I'm not "talking to the same people".

Seriously, if the surgeon wasn't one I highly desired, I would RUN away (not just walk) from having to talk to this young woman.

[vovo2013 35]

On 4/10/2019 at 4:00 PM, KarenLR75 said:

Just got off phone with CIGNA. They reviewed MY specific coverage and stated that this Is NOT one of their requirements.

We stepped through ALL of the requirements for their current policy which is effective thru 7/15/19.

I have a downloaded copy of the specific and current policy regarding bariatric surgery. The CIGNA rep on the phone was mystified as to how the dr's office feels that the 'six months with a nutritionist' is a requirement.

I called Dr. Dyslin's office staff back and was chided a bit for 'calling the insurance' which honestly upsets me. The young lady was nice but she is NOT proficient with reading/understanding medical verbiage and what it means. She said she and her office manager are confused YET they are looking at the same policy (policy 0051 for me) and they don't understand IT!!!! Said they will call insurance to check again but advised that I NOT CALL the insurance to 'get things confused'!! CONFUSED??!! I've been studying this for four years and since I am end up hospitalized every other years for the past several years I've become very INSURANCE PROFICIENT.

I like Dr. Dyslin but if his staff is so GREEN they can't interpret to me what is CLEAR AS DAY to both myself AND CIGNA....I'm a bit concerned I may need a different office..and I really liked the doc!!

HERE is the part they are hung up on which CIGNA said doesn't mean 6 back to back meetings with a nutritionist and I AGREE

A thorough multidisciplinary evaluation within the previous six months which includes ALL of the following: 

a description of the proposed procedure(s) 

a separate medical evaluation and/or a recommendation for bariatric surgery from a physician/ physician’s assistant/nurse practitioner other than the requesting surgeon or associated staff 

unequivocal clearance for bariatric surgery by a mental health provider 

a nutritional evaluation by a physician or registered dietician

Please Read page 6 of the Cigna Bariatric Surgery cover document. On that page it explains in detail why the office is making us go through a six month nutritional evaluation by a physician or registered dietitian. I know it is frustrating but we must follow the rules, so Cigna can pay for our surgeries.

Edited May 16, 2019 by vovo2013

[KarenLR75 518]

3 hours ago, vovo2013 said:

Please Read page 6 of the Cigna Bariatric Surgery cover document. On that page it explains in detail why the office is making us go through a six month nutritional evaluation by a physician or registered dietitian. I know it is frustrating but we must follow the rules, so Cigna can pay for our surgeries.

I definitely understand the concern; however, I have being working on losing weight, under supervision for more than a year now. I have lost 51 lbs. My weight loss has stalled due to knee and back issues. My ortho and spine dr's have encourage me to have bariatric surgery as both my knees need to be replaced. I've done all the PT that anyone can do. I took it slow and was determine to exhaust all available options plus I'm a personal believer in that you need to show you can have some personal discipline/skin in the game. The surgery is not a magic bullet. I consider it more of a nuclear detonation option. If it wasn't for finally finding out how painful a torn knee can be (after exercising too much) and then finding out I have so much arthritis in both knees that 2 diff orthos said I truly need knee replacement surgery (was SHOCKED)...I would NOT be going this route. After the past 15 months of doing supervised weight loss and finding out how it feels to be trapped by chronic pain, I made the decision (after therapy, etc.) that I wanted my life back MORE than I wanted to be able to eat 'any food' within reason. My surgeon gets this. I took the policy in with me to my 2nd appt with him and let him read it.

I'm ALL for having requirements and ensuring a patient is READY - mind, body and soul for this surgery. What I have a hard time accepting is misinterpreted requirements. I'd be ok if my surgeon imposed his own requirements. I've met both his requirements and the requirements of my insurance (plus some). I'm now still stuck at 51 lbs lost even though my pool has warmed up so I can swim. The chronic pain haunts my nights now as well as my days. I'm so ready for a change. I depend on ALL of the professionals I see - my surgeon, my primary dr, my cardiologist, my nutritionist, my psychologist (specializes in eating/weight issues), my ortho, my spine dr, and my psychiatrist. They ALL feel I'm ready and I've talked to CIGNA now 4 different times. THEY all feel I'm ready, so we'll see on next month's visit to my surgeon.

I'm not trying to RUSH anything. I have been thoughtful, mindful and have taken well more than 6 months to make sure this irreversible, irrevocable decision is the right thing to do.

I hope this makes some sense. I agree with caution and I agree with even doing more than my insurance requires. After reading page 6, I have done everything that is suggested there as well. I pray/cross fingers that after my next visit, the paperwork is put through. Then we shall see...

[vovo2013 35]

I definitely understand the concern; however, I have being working on losing weight, under supervision for more than a year now. I have lost 51 lbs. My weight loss has stalled due to knee and back issues. My ortho and spine dr's have encourage me to have bariatric surgery as both my knees need to be replaced. I've done all the PT that anyone can do. I took it slow and was determine to exhaust all available options plus I'm a personal believer in that you need to show you can have some personal discipline/skin in the game. The surgery is not a magic bullet. I consider it more of a nuclear detonation option. If it wasn't for finally finding out how painful a torn knee can be (after exercising too much) and then finding out I have so much arthritis in both knees that 2 diff orthos said I truly need knee replacement surgery (was SHOCKED)...I would NOT be going this route. After the past 15 months of doing supervised weight loss and finding out how it feels to be trapped by chronic pain, I made the decision (after therapy, etc.) that I wanted my life back MORE than I wanted to be able to eat 'any food' within reason. My surgeon gets this. I took the policy in with me to my 2nd appt with him and let him read it.
I'm ALL for having requirements and ensuring a patient is READY - mind, body and soul for this surgery. What I have a hard time accepting is misinterpreted requirements. I'd be ok if my surgeon imposed his own requirements. I've met both his requirements and the requirements of my insurance (plus some). I'm now still stuck at 51 lbs lost even though my pool has warmed up so I can swim. The chronic pain haunts my nights now as well as my days. I'm so ready for a change. I depend on ALL of the professionals I see - my surgeon, my primary dr, my cardiologist, my nutritionist, my psychologist (specializes in eating/weight issues), my ortho, my spine dr, and my psychiatrist. They ALL feel I'm ready and I've talked to CIGNA now 4 different times. THEY all feel I'm ready, so we'll see on next month's visit to my surgeon.
I'm not trying to RUSH anything. I have been thoughtful, mindful and have taken well more than 6 months to make sure this irreversible, irrevocable decision is the right thing to do.
I hope this makes some sense. I agree with caution and I agree with even doing more than my insurance requires. After reading page 6, I have done everything that is suggested there as well. I pray/cross fingers that after my next visit, the paperwork is put through. Then we shall see...

Have your surgeon did a peer to peer review with Cigna? He has all the documents in order then he needs to the a peer to peer review! This will help lush your case forward.

Sent from my SM-G973U using BariatricPal mobile app

[Add512 2]

I had surgery Monday. This particular plan through Cigna does not require any time period of medically managed visits for nutrition or weight loss and is accurate per the page I posted. I was approved first go within 3 days.