I was recently denied by Cigna for lap band surgery due to "lack of medically necessity." My secondary insurance, Tricare Prime, has advised that they will deny me as well for the same reason. I've decided to self-pay and plan on submitting the bill to both carriers after surgery to see if I receive any reimbursement at all. Has anyone tried this and been successful?

thanks,

ML

cw 280

gw 60

Claiming the cost of surgery as a medical deduction can save you some on your taxes, but it isn't going to "get your money back."

My PCM even wrote in her letter to my surgeon that although I am considered obese, I am considered "healthy." I suspect that word may have been a red alert for the insurance approver.

I wouldn't have submited that letter. Get a PCP who supports WLS and won't say stupid things like that!

Claiming the cost of surgery as a medical deduction can save you some on your taxes, but it isn't going to "get your money back."

I was going to say that! You can deduct the cost from your income and then whatever taxes you would have paid on that income get saved. So if you pay 20% in taxes and your lap band costs 10,000, then you can get reimbursed 2,000. If your tax rate is lower, you get even less back. If it's more, you get more but if your income is high enough, you can't even claim the lap band... it has to be 7% of your income or more. (So if your lap band is 7,000 or less and your income is over 100,000, you can't deduct it.)

Also, if you use your health care flex spending account to pay for part of the cost (assuming your company has this option), the money comes out of your pre-tax income and so you can't also claim this amount on your taxes. But you can claim the rest. The cool thing about using your FSA is that you can take the money out any time and spend the rest of the year putting it back. It's like an interest free loan from your company!

I too have been denied and denied by cigna..there is always a little something absent or not right. I dont think they approve anybody.. I am going to self pay, appeal, and get a lawyer. I feel frustrated and lied to..but not enough to lose sight of my goal. I have diabetes sleep apnea and depression..which is now worse..cigna is no friend of mine.

Thanks for your response KKS! I posted under a seperate thread that I had prepared to self-pay but shot off a pretty emotional appeal letter to cigna - they approved me 10 days later. Appeal it KKS...you will most likely be approved. I did not provide them with one extra piece of documentation when I appealed, which leads me to believe that they try to deny on the first try. Good luck to you! I am scheduled for banding on Thursday!!

Cigna is pretty insistant about the 6 consecutive months of medically supervised weight loss. I would see about coming up with that or following through on 6 consecutive months of medically supervised visits with a medical record for each of the 6 months with a weigh in at each visit. They are strict about this. The weight history of 5 yrs not so much. I know I have Cigna. I haven't been approved yet (because they are still awaiting my history and physical from the surgeon to submit) but I got that information from the staff at the weight loss center and directly from the Cigna website. Here is the link stating their coverage position on bariatric surgery (only if bariatric surgery is covered under your plan) http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0051_coveragepositioncriteria_bariatric_surgery.pdf

Hope this helps. My suggestion is appeal (and either "come up with" or complete 6 month visits)

I have Cigna as well and they told me up front even if it was deemed medically necessary they would not pay,I am Open Access and ended up in TJ,Mexico as a self pay.

Wow! Insurance really is a tough nut to crack. I have Cigna Open Access as well, but since my employer has a bariatric provision, I was able to at least submit the auth to them. They denied due to lack of consistent BMI and 6 month diet (i had docs for 4 out of 6 months). I appealed and they approved. I think it starts with the employer and how your insurance plan is written.

And how does it do a better job at decreasing weight than diet and exercise?

I haven't posted in a while, but I had the surgery Nov 8th- 2007 and at that time Tricare did not approve the surgery, so I was a self-pay. Then in Feb 208, Tricare approved the procedure retroactively to Feb 2007. I have submitted my claim form and am awaiting reimbursement from the hospital. If I am denied, I will contact my lawyer as well, since Tricare now approves the procedure and I qualify. I don't expect all my money back, but even $5 to 6K would be helpful..

So I'm not alone!!! Yeah! Its great to hear from someone who has gone through a similar experience. I am so excited to have this done and still plan on going after the insurance companies for some reimbursement. Please let me know how you make out!

I just got a call from my insurance comapany yesterday, they are going to reimburse me!!!! I resubmitted everything that they surgeon had submitted along with a letter explaining how I self-paid, which was cheaper than the insurance rate to a tune of $7k and that so far, I have been very sucessfull (down 57 lbs. so far). Additionally I explained how I fit the criteria. I cannot believe it, but it worked!!!!:cursing::wub::cool2::thumbup:

How is your situation going?

Has anyone been reimbursed by BC Anthem S cal for a program fee that you must pay before surgery even though having surgery done with an in network MD and at a BC Center of Excellance. I realise I have to pay before surgery but was thinking of trying to submit a claim to BC afterwards for the program fee