Physician Referral - I need help (frustrated)

J Connel
on 11/18/14 10:16 pm
VSG on 04/13/15

Good Morning!

I'm hoping that there might be someone here who has experienced either something similar or has advice for me.  I received my physician referral letter for the VSG procedure early in November.  The letter was a good referral, but my surgeon's office is telling me that CIGNA will deny the surgery if my PCP doesn't have the exact verbiage saying they were giving me "medical clearance" to pursue the procedure within the referral letter.

I talked to my PCP's office and they said they aren't comfortable using that terminology because it implies that they are clearing me for the surgery (ie, have done the pre-op labs, xrays, etc.).  Although both my surgeon's office and I have tried to make them understand that's not the case, I'm left in a bad position.  The surgeon's office is saying that it will be denied if they don't add this in, but I'm not sure my PCP will budge either.  I've been told they haven't had issues like this in the past with other doctors, so what the heck?  My PCP and the bariatric surgeon are even in the same large physician group (Lutheran).  I'm just stressed about it.

My question for all of you is.... did you need verbiage similar to this from the referring doctor?  Did you have trouble obtaining it?  If you did, what were your next steps?  I thought about seeing someone else (another doctor), but just worry about that too.  Will another doctor even see me and write that type of thing up when they have only seen me 1 time?  Any advice would be helpful.

And as another side note, the CPB with CIGNA simply states I need a referral from my PCP.  It doesn't specifically say they have to medically clear me for surgery.  I have argued this point with the surgeon, but they have said that although that's true, CIGNA has denied folks in the past because that verbiage was missing.

I'm frustrated.

JC

JC 5'3" HW: 283.2 SW: 224.6 CW: 140.0  M1: -20.0 M2: -10.2 M3: -13.6 M4: -6.4 M5: -7.2 M6: -7.8 M7: -6.2  M8: -5.8 M9: -2.2 M10: -5

GOAL WEIGHT ACHIEVED 2/2/16 

Follow my blog at: www.sleeveforme2014.wordpress.com

Bufflehead
on 11/18/14 10:36 pm - TN
VSG on 06/19/13

I did need that wording for my letter to Cigna, but my PCP was fine with providing it. If yours won't budge, I would suggest asking your surgeon's office for a referral to an alternate PCP that they believe will be able to help you. Usually your surgeon will have worked with many PCP's in your community and will know which ones are likeliest to help. Good luck!

 

    

J Connel
on 11/19/14 12:48 am
VSG on 04/13/15

I will ask them. I thought I asked before though and they said they don't refer patients to PCPs. Frustrating!! Thank you for the suggestion though. 

JC 5'3" HW: 283.2 SW: 224.6 CW: 140.0  M1: -20.0 M2: -10.2 M3: -13.6 M4: -6.4 M5: -7.2 M6: -7.8 M7: -6.2  M8: -5.8 M9: -2.2 M10: -5

GOAL WEIGHT ACHIEVED 2/2/16 

Follow my blog at: www.sleeveforme2014.wordpress.com

gmantek
on 11/18/14 10:49 pm

Same issue with Cigna - it must say the words medically cleared.  My PCP said she would have to do blood work and EKG before she was comfortable saying those words.  We did that, and she wrote the letter.  I found this PCP through my surgeon's office as he had sent many patients there before. Try asking if your surgeon will refer you to a WLS friendly PCP who has been through this before with your surgeon.  I know this is so frustrating!  You will get through this - but it sounds like you may need to start with a new PCP.  Good luck!

J Connel
on 11/19/14 12:46 am
VSG on 04/13/15

Thank you! I may have to consider a change for sure. Seems like Cigna needs that wording too, so I want to provide it initially. I feel weird going to a new doctor and asking for that though. Ugh!!

JC 5'3" HW: 283.2 SW: 224.6 CW: 140.0  M1: -20.0 M2: -10.2 M3: -13.6 M4: -6.4 M5: -7.2 M6: -7.8 M7: -6.2  M8: -5.8 M9: -2.2 M10: -5

GOAL WEIGHT ACHIEVED 2/2/16 

Follow my blog at: www.sleeveforme2014.wordpress.com

jenn1469
on 11/19/14 12:17 am

My doctor rewrote his letter once my they checked my heart and labs came back and he cleared me maybe that's what he's waiting for

Jennifer

    

J Connel
on 11/19/14 12:45 am
VSG on 04/13/15

Thanks Jennifer. I don't think my surgeon does labs and other things until I get approval from Cigna. I may need to ask my doctor what tests she needs to see run before she will give me that approval. I hate to be out more money though for tests that will have to be repeated.

JC 5'3" HW: 283.2 SW: 224.6 CW: 140.0  M1: -20.0 M2: -10.2 M3: -13.6 M4: -6.4 M5: -7.2 M6: -7.8 M7: -6.2  M8: -5.8 M9: -2.2 M10: -5

GOAL WEIGHT ACHIEVED 2/2/16 

Follow my blog at: www.sleeveforme2014.wordpress.com

gmantek
on 11/19/14 12:51 am

your PCP is the one that will have to run those tests, not surgeon.  I basically went in to someone that I had never seen before - was referred by my surgeons office. I met her, told her what i was considering, and that I needed PCP clearance.  She did a physical exam, complete with bloodwork.  Then when I took the original letter back and said it had to say medical clearance, she said she'd have to also do EKG.  Once that was clear, she gladly wrote my letter.  All that was covered by my insurance - Cigna. I hope that helps.

jenn1469
on 11/19/14 12:50 am

Get paper from surgeon of what labs need to be done than goto pcp and get yearly physical which insurance will pay for give pcp lab sheet and tell himyou need those labs tthat's i did and i wasn't charged anything but my copay

Jennifer

    

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