Seeking revision to DS...anticipating CIGNA issues

Hello ALL!

I had an RNY in 2000 and am just learning this past summer, via this board, that revisions are "a thing!" I  got insurance through my job this year because they had a plan that covered revisions.

My BMI is currently 44.9 and CIGNA requires a BMI of >50 for DS. I have lupus, arthritis, and systolic heart failure as my air co-morbidities.

The 64K questions is: Does that requirement mean for all DSers, or just first time DSers?

I have called the "1800 CIGNA" line 4 times now and the first three agents thought it meant only for first timers, were actually pretty confident of it and made a believer out of me. However, when I called today, another agent said no, it means for all bariatric patients. He had his manager to read over it and  the manager agrees. That stinks! There is room for ambiguity and a little confusion on the part of how the requirements are listed, I think.

Anyhoo, has anyone had any recent experience with battling CIGNA and how to proceed?

The guy today mentioned  a reauthorization and if it was denied to get the doctor to do a peer to peer call.  Do you think it is a BIG DEAL to ask for a peer to peer, or is it pretty common these days? Are there other things I should do first before requesting that?

I have an appointment with Dr. Ayoola (Frisco/Denton, TX) next Tuesday for an in initial consult and just want to know what to expect on my part and what to expect from his office and CIGNA.

All comments, suggestions, and advice are welcome!

Thanks so much!

Well it shows ya just how different Cigna is from place to place. I have Cigna, also thru my job, & to get any wls I only needed the bmi to be above 40 or 35 with co-morbidities. You're probably going to have to go thru hoops & fight, ins might be treating this as a revision & they probably have different standards b4 they'll pay for it. You might want to post this on the revision & DS forum to get more answers. Besides you might run into Ms Blatt, that's the only name I can think of that had the DS, she might have some answers. Good Luck!

1lasttime, 

Thanks so much for the encouragement! I am sure they will be treating it as a revision, but am almost repulsed at the need to be super obese to have it done! 

I am gearing up for the fight! =0)

MsBatt is one of the best informed around here, and one of very few patient enough to still come here, but there are many on the DS board and others. 

That 50 bmi thing can be easily overturned, and has been so many times. The criteria for all the main surgeries - RNY, sleeve and DS - all have the same requirements of 40 bmi, or 35 with co-morbs. 

Appeal the 50 bmi.

Amy, 

Yes, I got my surgeon's name from one of MsBatt's previous posts. She rocks!

I am gearing up for the battle ahead--body, mind, and spirit--and am glad to hear you say that you have read of others that have been able to have it overturned. 

I have posted this on several boards, so we will see what happens. 

Thanks for the encouragement! I haven't posted since the website was called AMOS....I can't even remember what it stood for back then. =0)

The fact that you have arthritis means that you NEED to be able to take NSAIDs. That's one string in your appeal bow, and I'm sure there are others.

The whole "BMI greater than 50" thing is BULL**** The ASMBA says that any patient who qualifies for WLS qualifies for the DS, period. The DS is also better at treating or preventing some medical conditions (pretty much ALL of them other than GERD!), and that's another string for your bow.

Definitely put in for the revision, and if they deny, then appeal all the way up the line. There are folks in some of the Face Book DS-oriented groups who can give you a lot more help than I can (some of the work for insurance companies, some are medical professionals, some are lawyers---and they'll help you pro bono.)

MSBatt, 

Thanks so much for posting. Yes, I knew that, about the NSAIDS, but it is definitely something I need to remember to state in writing and during my consult on Tuesday. I did not know about the ASMBA statement. I will try to google it, if you have a direct link, please send it. Also thanks for the information about the Fb page. I am not a face booker, but may need to become one. =)

Stringing my bow, sister, stringing my bow! =0)

I an right there with you and Cigna concerns. I, too, wondered if the 50 BMI for the DS was for all DS or first surgery only. I had the sleeve 3 yrs ago and got off a lot of weight but never got my BMI into normal nor to m"my" goal weight. I am in the process of working towards a revision

A word of warning for you. 

There has been a load of sleevers wanting revision going to surgeons that are primarily RNY (they SAY they know the DS, but don't actually have the training) and cut up the sleeve and make it all into RNY.

It sounds like you already know you have the first half of the most effective surgery, so be wary of going to a surgeon that doesn't REALLY have training in all the surgeries.

Thanks for the advice,  but I am in excellent hands, Dr Stephen Boyce in Knoxville, TN. He trains others surgeons on the DS ;)