Question:
can anyone give me the criteria that cigna has for gastric bypass??
— JANICE M. (posted on September 16, 2003)
September 15, 2003
Best thing to do is call customer service and ask for the criteria in
writing. It varies from state to state. Back when I had it in 2002, I
must have been 100 lbs overweight for at least 5 years, have multiple
co-morbidities, have attempted 3 12-week physician supervised diet
attempts, one of which had to have been in the last year. I had to do the
last one prior to approval. I have heard in November 2002, that Cigna
changed the physician supervised diet attempts to 2 26-week physician
supervised diet attempts. The best thing to do is get it in writing for
your state.
— Cathy S.
September 16, 2003
Cigna can be very arbitrary. They require 2 26 week diets supervised by dr.
one in the last year. Must be medically necessary. But even if you meet
these they might find another reason to stall or deny. They also have
approved others who have not met these requirements. There is no rhyme or
reason to the way they do things. Good luck. Get an appeal together at the
same time you submit and make sure you have the dr supervised diet. They
also want a multidisciplinary exam. (nutritionist, dietician, psych. etc)
— jaetex
September 17, 2003
Cigna PPO approved my surgery within 6 weeks of submission. I had
hypertension and some orthopedic problems and high cholesterol.
— Margaret G.
September 17, 2003
Janelle is 100% correct. I'd also like to add that even if you have all
your ducks in a row, Cigna likes to deny the first go around because most
people will not appeal. It saves them money in the long run if some just
give up and go away. Dont be surprised if you dont get any help from
Cigna's customer no-service. They kept telling me to ask my doctor for
info, that I didnt have access to it. Go figure. Cigna will pay but you
have to play by their rules. Good luck. ~Sidney~ Open RNY 10-23-02 down
115+ and counting
— Siddy I.
September 19, 2003
Hi Janice, I am in the first stages of this process too! I have Cigna HMO
and I called them and all they would tell me was a doctor has to submit
paper work stating it's medically necessary. I didn't think of asking for
a written statement...good idea. It is just going to vary person to
person. I was reading another area from this website on insurance and most
people with Cigna got approved and alot on the first try. I wish you the
best of luck!
— Gia L.
September 19, 2003
The people at cigna member services are clueless.For over a year they
continually gave me incorrect policy information.Lately it doesn't seem to
matter if you do meet their ever changing criteria as alot of people are
still getting denied.I heard that after the new year they aren't going to
cover wls at all.
— jennifer A.
September 21, 2003
I have cigna and all ICan tell you is do what they ask they needed from me
all my 5 years medical recores .A letter from my primary care DR and 13
weeks of suprivesed diet and lab work and a pshy evalation and then I got
approvel in 5 weeks
— Laura Polson
October 3, 2003
I too called Cigna and asked for the guidelines and requirements for WLS
and was given BS. Thanks to the insurance department at BTC and my own
denial, here are the current requirements (as of 10-3-03 and i'm sure
they're subject to change at Cigna's will):
2 26-week professionally supervised diets with at least monthly weigh
ins.(they will accept weight watchers if you have the stamped weigh in
card). My policy only required one diet, but I seem to be in the minority.
Also, one of these diets has to have taken place in the past 12 months.
A psychiatric evaluation
A Nutritionist/Dietitian evaluation
A medical evaluation from your PCP (make sure that it states that you're
cleared for surgery and that it's a medical necessity)
Proof of comorbities and that you've attempted to treat these. (Untreated
comorbs will keep you from getting approved, not to mention it's
dangerous)
Medical records going back at least five years.
I would get a letter from any surgeon, specialist, OBGYN, podiatrist,
cardiologist, ANYONE who could speak on your behalf that this surgery is
needed and would help your current health conditions...
Good luck!
— April S.
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