Question:
WHAT IS THIS SUPPOSE TO MEAN?
— Brandyraj (posted on April 29, 2003)
April 28, 2003
Brandy...please read my profile. This is typical of Cigna. What they are
saying is that you do not have enough diet history to prove that you've
tried less invasive means of weight loss. It's a crock because we have ALL
tried ALL the diets ever made LOL and they don't work!! Feel free to email
me personally if you have questions. I was approved after external review
on Feb 14th, so read my profile around that time. Good luck!!! =)
— Kim D.
April 28, 2003
First of all, let me give you a hug. Aren't families great! Be thankful
that they live elsewhere and you can control your contact. It sounds to me
that you don't have the two six month weight loss attempts. Go see your PCP
each month to get weighed and see if she has any programs she can help you
with. If possible join a gym and start exercising. You don't need to take
the drugs - the insurance companies obviously don't think they are
effective or they would pay for them. I'm waiting for the law suit on that.
Anyway, the rest sounds like medical neccessity which is appealable. I
understand about the money situation and that may be insurmountable at this
time. Save your money until you can afford some kind of six month program.
I did Weight Watchers but that's expensive (and I have Humana HMO. Can your
family give you the money? Hey Mom, this is what I need. My own children
are a little younger than you (22, 20, 20) and I know I would do without to
help them with a medical problem as I know you would for your daughter.
Hang in there. Peace.
— Sunny S.
April 29, 2003
I looked at the NIH/NHLBI consensus statement from 1998. No where in there
does it give any outcomes data! So, they are recommending supervised diet
therapy, but they don't even give any evidence that it works. I think
that if you do some research you could make a convincing case for getting
surgery approved. (Look for data that shows diets don't work in the long
run, but surgery does.)
— koogy
April 29, 2003
Hi Brandy. I have CIGNA insurance as well. However I ahve a POS plan
instead of your HMO. Basically the insurance company is stating whatever
info Dr. Blackstone sent in on your behalf didn't meet their criteria for
coverage. For obesity surgery to be considered considered under your plan,
you must prove you have some co-morbids. Do you? You must have a BMI of
at least 39. (At least under my plan anyway). You must also have at least
two 6-month weightloss attempts monitored by a "professional",
and one of the attempts has to have ended within the last calendar year.
Your letter lists what that monitoring must entail. Have you been
supervised? "Your plan includes the following medical necessity
definition- Medically necessary covered Services and Supplies are those
Services and Supplies that are determined by the Health plan Medical
Director to be: no more than required to meet your basic health
needs". I think if you prove you have the co-morbids, the surgery
will contribute to meeting your "basic healthcare needs". You
definately need to take them up on their offer to suppply you with their
"guidelines". I haven't read your profile to know what your
situation is about documented diet attempts, but I will say if you don't
have them, get started now. Your PCP can monitor you each month for the
required number of months. I've heard a lot of people who say HMO's stink.
Good luck to you, Kimberly.
— Kimberly S.
May 5, 2003
Brandy, sorry to hear about your problem. I used to work in insurance
claims processing, and I know how claims are coded. From the first line of
your letter, the 278.01 is what's called a diagnosis code. This code
represents a diagnosis of morbid obesity. That diagnosis is not usually
covered for any procedure. I would ask your doctor to resubmit your
request for approval using the diagnosis code for one of your
co-morbidities. Diabetes, high blood pressure, joint problems, asthma, and
others may increase your chances of being approved. Above all else, talk
to your doctor. Appeal the decision. Sometimes insurance companies deny
things automatically and assume you won't take further action. Hope things
turn out for you.
— badger411
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