Cigna drama........

BobbieDoll · April 11, 2008

I completed all of Cigna's requirements and my surgeon sent the paperwork in on 3/3. He told me that I would get a letter from Cigna telling me they needed more information but just to ignore it. He also told me that if I call Cigna, they will tell me they didn't have any of my paperwork.

All of those things happened. Then about 2 weeks later, I found out I was denied due to not showing "co-morbidity - such as a serious cardiopulmonary problem, type 2 diabetes, hypertension, coronary artery disease or pulmonary hypertension -that have failed to respond adequately to appropriate medical management".

I didn't know what to do next. The letter said my doctor would need to appeal. Everytime I called Cigna, I got someone else, each person telling me something different. On the internet I found an appeal form for Cigna but it says that if you are appealing a sugery denial, to fill out a stage one something or another. So again I called Cigna and was lucky enough to get someone who knew what they were doing. She told me if I appeal, I could not go back and do a peer-to-peer. She advised me to do a peer-to-peer first and if that didn't work, appeal.

Yesterday I called my PCP's office and asked the medical assistant if she would call Cigna and ask how to go about setting up a peer-to-peer with my doctor. (That is a direct phone call between my PCP and a Cigna doctor to discuss why I should have the surgery. I doubt if my PCP even knows who I am. I always went to the PA so I didn't know how this was going to work out.) Later on in the day, I answered the phone and it was the PA calling. She said she was going to put me on speakerphone so we could discuss the situation. Then she told me I was approved. There was alot of cheering in the background, from the other staff members. Wow! They called Cigna, was able to set up a peer-to-peer that day. She explained to the Cigna doctor that the surgery was medically necessary and they approved it! She told them I couldn't walk very far without having to stop and rest. That was the co-morbidity.

I can't tell you how important it is to have a doctor, or in my case, a PA, who will help you get the insurance approval.

I have the all important approval number and will get my surgery date on Monday. :thumbup:YIPPEE! :thumbup:

Carrie_C · April 12, 2008

That's great! I am waiting on approval from Cigna. They have denied me 2 times. Hopefully I will get approved this time. What type of Cigna do you have?

BobbieDoll · April 12, 2008

I have access plus. Why were you denied? Dealing with the insurance company has been very frustrating. Good luck to you getting approved this time.

Carrie_C · April 12, 2008

I have the same type. I was denied the first time bacause they didn't receive the nutrition eval (so they said anyway). The second time, they said that they needed a second letter from the RD showing that I had the eval. I don't know why they needed 2 letters. It has been almost 2 weeks since the surgeons office filed the appeal, and I haven't heard anything, so I am hoping that is a good sign. The first time it took them less than a week to deny me and the second time they denied me in less than a day. I have comorbidities that are being controlled, so I don't know if they will deny me because of that. But my BMI is 41, so I don't see what it would matter about comorbidities if my BMI is over 40. What is your BMI?

BobbieDoll · April 13, 2008

It is 38 so I had to have at least one co-morbidity (that word sounds creepy) to qualify. You should qualify since you are 40. I am betting that you will get approval. Maybe we will be having surgery around the same time.