Question:
What do I need to do??
I have a CIGNA PPO which does cover the RNY procedure, however I was denied by CIGNA and here is what they said: "Although the patient has benefits, the information provided does not meet the criteria for medical necessity for gastric bypass. Even the the patient has a BMI=44, there is no documentation of an evaluation by an internist/family doctor, and a dietary history of two failed supervised diets of at least 26 weeks duration, one of which was within the past year, with monthly weigh-ins. Ther is no documentation of a multi-disciplinary team. Based on CIGNA's Clinical Resource Tools." HELP!!!! Jack — jaaxo (posted on August 4, 2003)
August 3, 2003
I swear, insurance companies must have a dart board, and whereever the dart
lands determines their answer for that patient! I have cigna pos nj, and
thankfully was approved the first time out. I've got lots of diet history,
diet center, weight watchers, stuff like that, but certainly nothing long
term involving a doctor, and nothing documented in the last year. You need
to appeal, and I'd suggest just in case the appeal is denied, start seeing
your primary physician for a weight loss program and regular weigh ins. The
worst that will happen is that you'll have your WLS put off a year. Very
frustrating. I do sincerely wish you luck in your journey. Linda
— lorien
August 3, 2003
This is saying you need a PCP visit about the morbid obesity, and two diets
of at least 6-months with documentable monthly weigh-ins, at least one of
which within the past year. So if you don't have the diet history they are
looking for, go see your PCP and get them to recommend a diet/eating plan
and stick to it for six months and see him/her every month for your
weigh-ins. If you loose weight, you will still be MO, if you don't loose
weight, you've lost 6 months but it will go quickly.
I would also call and ask your insurance define the "multidisciplinary
team" they may mean an eval by psych and/or nutrition, but this term
isn't clear enough.
— bethybb
August 4, 2003
Jack - Cigna just put that new rule of the 26 week diet into effect in
June. When did your doctors office send in your paper work? I work in a
doctors office that does RNY. If they sent it in prior to their change, you
may be able to get it overturned, if you met the previous diet guidelines.
Like I said they just changed it from ( I believe) 13 weeks of a medically
supervised diet history. Good luck! Ashley
— Ashley S.
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