Denied again... but this time...

Lori F.
on 8/1/12 1:50 pm - Chula Vista, CA

...I may have a chance... Cigna denied a brand new auth requesting revision from band to DS for two reasons:

1. WLS is not a covered benefit (it is when medically necessary)

and

2. The doc is not in my network (but he is according to their website and they approved consults with this doc and paid the claims last Sept)

Do I appeal or do I ask for a peer-to-peer? Are these the only two points I have to refute, or can they make stuff up later?

Let me know what you know, please~!
Thanks for helping!

Pre-band highest weight: 244
Pre-band surgery weight: 233
Lowest: 199 ( for, like, a day)
CW: 260 (yes, with the band!)

Current Fill: 5cc in 10cc band
BMI: 49

Valerie G.
on 8/1/12 10:18 pm - Northwest Mountains, GA

DS on 10/31/05

This definitely sounds like you have something to work with. The peer-to-peer is a good idea, but you want to clear up why doc is not in network now. They may have let the contract drop for 2012. Call his office and speak with someone who knows more detail about that. If that's the only problem, then you find another surgeon in-network.

Valerie
DS 2005

There is room on this earth for all of God's creatures..
next to the mashed potatoes

twilit_tera
on 8/2/12 8:56 am

What's a peer-to-peer?

Lori F.
on 8/2/12 11:17 am - Chula Vista, CA

Lap Band on 07/06/07

A peer-to-peer is a conference that the surgeon holds with a doc at the insurance company regarding a denied authorization. This is done before the appeal and is really only for use when the reason for the denial is medical in nature (as opposed to benefits or procedural related). And the surgeon has to agree to do it...

Pre-band highest weight: 244
Pre-band surgery weight: 233
Lowest: 199 ( for, like, a day)
CW: 260 (yes, with the band!)

Current Fill: 5cc in 10cc band
BMI: 49

Crazeru
on 8/2/12 11:25 am

DS on 04/17/08

What about the Calif Department of Managed Health Care? I had an independent medical review and Kaiser lost and I was able to get my DS.

Chris
HW/225 - 5'1" ~ SW/205/after surgery 215 ~ CW/145~ BMI-25.8~Normal BMI 132 ~DS Dr Rabkin 4/17/08
Plastics in Monterrey - See Group on OH Dr Sauceda Jan 13, 2011
LBL, BL, small thigh lift, arms & a full facelift on 1/17/11 UBL 1/21/13
Love my Body by Sauceda

Whit
on 8/2/12 1:50 pm, edited 8/2/12 1:50 am

Revision on 12/10/12

Hi,
I know this is off topic but I was born and raised in Chula Vista. I miss it...

Revision from RNY to DS 12/10/12 Dr. Ara Kesishian BMI: 19

Created by MyFitnessPal - Nutrition Facts For Foods

smileyjamie72
on 8/2/12 7:20 pm - Palmer, AK

DS on 12/29/11

BIG HUGS to you, Lori!!!! You KEEP FIGHTING!!!!!

Have you visited us over on Weightlosssurgery.ProBoards.com?

RNY 2/26/2002                           DS 12/29/2011
HW 317                                     SW 263 BMI 45.1
SW 298                                     CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003

Normal BMI 24.8 is my GOAL!!!

GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**

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