Cigna Can't Make Up Its Mind

[devotion 41]

Unbelievable. Cigna cannot determine whether weight loss surgery is covered or not under my insurance policy. On the phone, I have been told yes, it is covered only be told later that there is a a specific exclusion in my policy for weight loss surgery. I was ready to self pay. I saw the surgeon this week for an initial consult and tentatively scheduled surgery for the first week in November. BUT the bariatric coordinator just called - Cigna called her and said they thought WLS is covered under my policy. The bariatric coordinator let them know that Cigna said it is not covered when she verified my benefits. So the Cigna rep is "double checking" and will get back to her. I can't believe this! How difficult is it to determine whether I'm covered or not. Has anyone experienced this type of thing before?

Also, if a miracle happens and I am covered, what kind of hoops will I have to jump through with Cigna? Any experiences with Cigna in this regard would be much appreciated.

Thanks in advance!

[Maisey 260]

What matters is what your policy with the insurance company covers, not the company in general.

For example, for years my insurance company covered weight management services and surgery in many policies. However, policies negotiated between my employer and the insurance company specifically excluded it. Therefore, even if a doctor affiliated with the insurance company recommended surgery, it would not be covered for me.

Seeing how you are already getting conflicting information, I would make sure you get everything in writing going forward.

[devotion 41]

1 hour ago, Maisey said:

What matters is what your policy with the insurance company covers, not the company in general.

For example, for years my insurance company covered weight management services and surgery in many policies. However, policies negotiated between my employer and the insurance company specifically excluded it. Therefore, even if a doctor affiliated with the insurance company recommended surgery, it would not be covered for me.

Seeing how you are already getting conflicting information, I would make sure you get everything in writing going forward.

Thank you so much. What's weird is that Cigna has said my policy covers WLS and then has said that WLS is excluded under my policy. And now they are telling the coordinator at my surgeon's office that my policy DOES cover WLS. It's very disconcerting. I just want to know one way or the other.

[Maisey 260]

So you have a way to access your policy online?

[devotion 41]

1 hour ago, Maisey said:

So you have a way to access your policy online?

Unfortunately I can only see a summary of benefits, but not the actual policy. I will request it.

[vikingbeast 985]

I have CIGNA, but they are just the coordinator (my employer self insures).

The requirements they had were ridiculously easy:

1. Letter from my PCP recommending me for surgery.
2. New Patient Orientation / Post-Op Nutrition Education (combined into one)
3. Surgeon Presentation ("This is what gastric bypass is... this is what sleeve gastrectomy is...")
4. Psychological Clearance
5. Attendance at one bariatric support group meeting
6. About 20 pages of forms, quizzes, etc. I had to send in.

That was it.

[devotion 41]

1 hour ago, vikingbeast said:

I have CIGNA, but they are just the coordinator (my employer self insures).

The requirements they had were ridiculously easy:

1. Letter from my PCP recommending me for surgery.
2. New Patient Orientation / Post-Op Nutrition Education (combined into one)
3. Surgeon Presentation ("This is what gastric bypass is... this is what sleeve gastrectomy is...")
4. Psychological Clearance
5. Attendance at one bariatric support group meeting
6. About 20 pages of forms, quizzes, etc. I had to send in.

That was it.

Thank you @vikingbeast!

[catwoman7 10,874]

the people above are correct. Most insurance companies cover it, but the employer can pick and choose which services it wants put in the policies it offers its employees. Some employers don't want to include bariatric surgery included in their policies because of the cost.

[devotion 41]

2 hours ago, catwoman7 said:

the people above are correct. Most insurance companies cover it, but the employer can pick and choose which services it wants put in the policies it offers its employees. Some employers don't want to include bariatric surgery included in their policies because of the cost.

Thank you! Honestly, I am not going to rely on the insurance company's verbal statements. I'll believe that I have coverage when I see that they have approved the surgery. In the meantime, I'm just going to plan to self pay. That way, I will be pleasantly surprised if I am covered. Thanks all for the responses!

[devotion 41]

I can't believe it. I just found out I am approved! It is on Cigna's website. I'll feel better once I speak to my surgeon's office, but this is amazing news.

Sent from my SM-G981U using BariatricPal mobile app

[vikingbeast 985]

Congratulations!

[Sunnyway 344]

On 8/26/2021 at 1:01 PM, devotion said:

Unbelievable. Cigna cannot determine whether weight loss surgery is covered or not under my insurance policy. On the phone, I have been told yes, it is covered only be told later that there is a a specific exclusion in my policy for weight loss surgery. I was ready to self pay. I saw the surgeon this week for an initial consult and tentatively scheduled surgery for the first week in November. BUT the bariatric coordinator just called - Cigna called her and said they thought WLS is covered under my policy. The bariatric coordinator let them know that Cigna said it is not covered when she verified my benefits. So the Cigna rep is "double checking" and will get back to her. I can't believe this! How difficult is it to determine whether I'm covered or not. Has anyone experienced this type of thing before?

Also, if a miracle happens and I am covered, what kind of hoops will I have to jump through with Cigna? Any experiences with Cigna in this regard would be much appreciated.

Most health insurance claims are processed by high school graduates with minimal training. A different person sees it each time. They "top sheet" the records rather than looking closely. They make lots of mistakes. Contest every denial. They have to prove it's not covered by showing the portion of the policy with the exclusion. Escalate review up to management. Your doctor can also ask for a peer-to-peer review.

You can file a complaint with your state's Dept of Insurance. Cigna will be required to reply within 30 days of receiving notice of the complaint. Often this bumps the claim up to a higher claim handler or supervisor who reverses the prior decision.