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Anyone denied AND they meet ALL criteria/co-morbidities



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My packet will be submitted to CIGNA next week. I have Open Access Plan, and my surgeon’s practice is a Cigna Center For Excellence.
Has anyone been denied despite meeting every criteria/co-morbidities articulated by the insurer?
Just curious.
Thanks.

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55 minutes ago, Mariann812 said:

My packet will be submitted to CIGNA next week. I have Open Access Plan, and my surgeon’s practice is a Cigna Center For Excellence.
Has anyone been denied despite meeting every criteria/co-morbidities articulated by the insurer?
Just curious.
Thanks.

is your insurance thru the marketplace? like obamacare?

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11 minutes ago, liveaboard15 said:

is your insurance thru the marketplace? like obamacare?

No. It’s not through the marketplace.

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as long as your insurance covers bariatric surgery, I'd be very surprised if you were denied.

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7 hours ago, Mariann812 said:

My packet will be submitted to CIGNA next week. I have Open Access Plan, and my surgeon’s practice is a Cigna Center For Excellence.
Has anyone been denied despite meeting every criteria/co-morbidities articulated by the insurer?
Just curious.
Thanks.

Before my company switched to BCBS of Illinois I had Cigna. They are FANTASTIC about approving things as long as it's medically necessary. For example, I have MS. I take 4 medications for it. ONE of them (Tecfidera) is $8,900 per MONTH. As soon as they had the docs on file that I have MS, they covered it no questions asked with just a $10 copay. My other 3 meds total $3300 per month. Same thing. They also covered my 6 x-rays (3 with and 3 without contrast) every 6 months, no questions asked, because they are needed for my MS. So if your surgeon submits everything to them and lets them know it's medically necessary, I can almost guarantee it'll be covered no problem.

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9 hours ago, Future Sleeve Diva said:

Before my company switched to BCBS of Illinois I had Cigna. They are FANTASTIC about approving things as long as it's medically necessary. For example, I have MS. I take 4 medications for it. ONE of them (Tecfidera) is $8,900 per MONTH. As soon as they had the docs on file that I have MS, they covered it no questions asked with just a $10 copay. My other 3 meds total $3300 per month. Same thing. They also covered my 6 x-rays (3 with and 3 without contrast) every 6 months, no questions asked, because they are needed for my MS. So if your surgeon submits everything to them and lets them know it's medically necessary, I can almost guarantee it'll be covered no problem.

Thank you. I feel much better having read that. You apparently, like me, have excellent coverage through Cigna. Whenever I speak with them, they invariably say: ‘your husband has an excellent plan.’ They have covered my pre-procedure tests and those were $$$.
thanks again and good luck to you. My cousin has MS, but she has been given every med available with no good result. 😢

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3 hours ago, Mariann812 said:

Thank you. I feel much better having read that. You apparently, like me, have excellent coverage through Cigna. Whenever I speak with them, they invariably say: ‘your husband has an excellent plan.’ They have covered my pre-procedure tests and those were $$$.
thanks again and good luck to you. My cousin has MS, but she has been given every med available with no good result. 😢

Yes. When I had them, they would comment that my company chose an excellent plan. Worth every penny, believe me. Luckily, BCBS of Illinois is just as good, althogh quite a bit more expensive. Still worth it, though. i will say, I miss Cigna. Absolutely loved them.

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4 hours ago, Mariann812 said:

My cousin has MS, but she has been given every med available with no good result. 😢

I'm sorry to hear this. What kind does she have? I have RRMS (relapsing-remitting MS). It can be a struggle at times, but there are really good medications out there, and new ones coming out all the time. I'm on the strongest oral med there is, but there's also a lot of injections and IV infusions. Has she tried those?

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6 minutes ago, Future Sleeve Diva said:

I'm sorry to hear this. What kind does she have? I have RRMS (relapsing-remitting MS). It can be a struggle at times, but there are really good medications out there, and new ones coming out all the time. I'm on the strongest oral med there is, but there's also a lot of injections and IV infusions. Has she tried those?

She tells me that her doctors at Duke have tried everything that there is to try, I don’t know what type she has, but she did mention a year ago that her doctors had exhausted all options.

you keep fighting the good fight. ❤️

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Just now, Mariann812 said:

She tells me that her doctors at Duke have tried everything that there is to try, I don’t know what type she has, but she did mention a year ago that her doctors had exhausted all options.

you keep fighting the good fight. ❤️

That's so sad! There's so many options out there, to have gone through them all and gotten no relief hurts my heart. I hope she gets some help really soon. And thank you for your kind words. I'm stable for now, have bn for the last couple years, but I still get the breakthrough tremors and spasms and head fog (and SERIOUS memory issues) but I've learned to live with them. I will gladly take that over the full blown flares any day.

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On 04/14/2022 at 16:35, Mariann812 said:

My packet will be submitted to CIGNA next week. I have Open Access Plan, and my surgeon’s practice is a Cigna Center For Excellence.

Has anyone been denied despite meeting every criteria/co-morbidities articulated by the insurer?

Just curious.

Thanks.

I also have Cigna, but Sisco is giving me hell trying to approve.

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On 05/19/2022 at 19:11, vmarlau said:


I also have Cigna, but Sisco is giving me hell trying to approve.

I’m sorry they are giving you difficulty..
I was approved about 2 weeks ago and my surgery is 6/8.
I hope you get your approval soon.

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What was the reason for the denial? The denial letter should state the reason why like missing criteria, not a covered procedure (not all plans cover bariatric surgery, especially if it’s employer sponsored coverage), alternative treatment needed for x amount of time?

Cigna is a great insurer, i like them almost as much as i love BCBS/Anthem so there should be a concrete reason for the denial.

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I totally misread this as you were denied. Oops.

But for those with employer sponsored health insurance:
Read the denial letter. It will give you information on why you were denied and next steps. Common reasons for denial:
1. Missing criteria
2. Not a covered service under the plan (employers can exclude bariatric coverage from their plans or it’s not offered at certain market sizes such as under 100/small group plans)
3. Alternative treatment/step therapy required such as nutritional counseling, medically supervised weight loss
4. Procedure not covered; alternative procedure covered
Example: duodenal switch isn’t covered but the sleeve is
5. Age -either too young or too old

All denial letters will give you next steps to take action and appeal the decision. I suggest work with your provider to file the appeal.

I’ve been in health insurance for nearly a decade and i have seen these denials before.

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YES, I was initially denied. I have BCBS of Minnesota. My BMI was 38.1 with two co-morbidities (pre-diabetic and high blood pressure). They DENIED surgery because I take BP medication and therefore my blood pressure is under control and no longer a risk. That is so ridiculous! Fortunately, the bariatric office manager fought for me and argued with them. BCBS approved me the next day. I had surgery on 4/12/22.

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