The Saga of CIGNA - the Duplicitous and Unethical Insurance Co

Hey all!  I haven’t been around in a few weeks because of hell at work and then other issues at home, but I had to take the time today and let you guys know what is going on.

When my surgeon first submitted my surgery predetermination letter to CIGNA I received a letter stating medical necessity of revision had been established but they were denying me for the DS as they considered it experimental/investigational.  So started my long, drawn out appeals process that has now come to the external review process.  I received a letter in the mail yesterday from CIGNA with the decision of IMEDECS, the IRO that reviewed my external appeal, and while I have won one battle, CIGNA, the sneaky *******s, have thrown up another and I am beyond furious!!

The rep from IMEDECS states, “There is insufficient information to determine medical necessity for the requested intervention.  This request is for a revision from a VBG” (which is NOT my original surgery but the SRVG) “to a DS.”  He goes on to say there is no proof of anatomical complications (meaning ring failure, which I have), and no updated diet and psychological evaluation, and that he would need these documents to determine medical necessity for a revision.  But he does go on to say that if medical necessity is proven then the DS is an appropriate choice for revision surgery especially for someone who has had a prior failed surgery, and, my favorite sentence in the whole damn letter “It is considered to be one of the standard operations for treatment of morbid obesity and is not investigational or experimental.”  HALLELUJAH!!!!   Then “Numerous long-term outcome studies have been performed within the US and around the world. Weight loss results have sustained the test of time and it is considered to be superior to that of RYGPB in most studies.”  YIPPEE SKIPPEE, PRAISE THE LORD!!

So, in effect, he has overturned their denial based on the DS being “investigational and experimental” but can’t approve the revision BECAUSE, and here is where CIGNA is continuing to be ********! they DID NOT submit my endoscopy results showing ring failure, they DID NOT submit my updated diet history and they DID NOT submit my psychological evaluation to IMEDECS, and I’m pretty sure they DID NOT tell IMEDECS to evaluate only the contention that the DS is “investigational/experimental.”  They KNEW beforehand he would not overturn their decision because the doctor conducting the review did not know that CIGNA had already approved me for revision surgery (even though I mentioned it in my letter to the reviewer), and without those documents he would not approve me for revision surgery whether or not he determined the DS was experimental!! 

So now CIGNA’s letter says “ We’re sorry that this response is not entirely favorable.  The independent expert’s review and decision upholds our original determination.  Therefore, CIGNA will not authorize payment of the treatment or services that were the subject of your appeal.” 

Excuse my language, but the f*@&ers are jumping on the fact that he can’t approve the revision based on their lack of submitting all the paperwork and are trying to say he is upholding their original decision when, in fact, he is not because their original denial wasn’t for the revision itself but the procedure I wanted, stating the DS is investigational and experimental.  Needless to say I WILL be calling IMEDECS to let them know of CIGNA’s duplicity AND I’ll be calling CIGNA tomorrow and will be throwing one hellacious fit!  I have copies of the letters stating they have already approved the request for revision surgery and now I have a letter from the IRO showing the DS is an acceptable procedure.  I am now armed and ready to send everything to the IN Dept of Insurance, too, plus I’m going to file a complaint with the Better Business Bureau AND I’m going to call my local television station that just LOVES to report on shady insurance companies!

If CIGNA thinks this is over, they are in for a major shock!!

But to all of you out there who have CIGNA, know that they are going to fail in their bull**** campaign to deny coverage of the DS.  I have one more hurdle to jump and then they will have no other recourse but approve me and hopefully this will help pave the way for others to get approved, too.