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The Surgery Approval Process

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In December 2010, after several years of deliberation, I decided conclusively that I wanted to have weight loss surgery. I had tried so many different “conservative means” of weight loss, and I was ready to do something significant. I discussed weight loss surgery with my primary care doctor, endocrinologist, gynecologist, and my pulmonology sleep specialist. All were in agreement that surgery was medically necessary to alleviate my obesity-related health conditions.

Even though I had done hours and hours of research about weight loss surgery, I wasn’t exactly sure what I needed to do get my insurance company’s approval. There’s a lot of websites that talk about weight loss surgery, and give a rundown of  requirements, but it’s plan-specific. I hopped on the Cigna website to verify my benefits, find a surgeon who was a preferred provider,  and determine the gastric bypass surgery approval requirements.

The gastric bypass insurance approval process varies from insurer to insurer, but most companies have similar guidelines. You have to get clearance from your primary doctor for surgery, gather medical records, choose a surgeon and find out what the office procedures are to begin the surgery process. Cigna has a guideline that is more strict and involved than some insurance companies, namely explicit documentation of 6 months of medically-supervised weight loss attempts.

It took a few weeks to get my medical records from other doctors, and get my primary care doctor to complete a letter of medical necessity. At that point, I called up the surgeon’s office and made an appointment for their introductory weight loss surgery class. This 4 hour class outlined the different weight loss surgery options, risks and benefits, and a Q&A session with one of the surgeons. After I class, I was given a large packet of paperwork to fill out, with a checklist of medical records I needed to acquire. About two weeks later, I’d requested all of my medical records from the last 6 years (in 4 states, no less!) and was put on the waiting list.

A few weeks later, I had my appointment to meet with Dr. Sherman Smith, the bariatric surgeon I had chosen for my procedure. We went over my health history, he gave me an examination, and he gathered the information he needed to write a letter of medical necessity for surgery. Originally, I was planning on having a sleeve gastrectomy, but after meeting with Dr Smith, he strongly recommended a roux-en-y laparoscopic gastric bypass instead.

About 2 weeks after my visit with Dr. Smith, I got a call from the office saying that my surgery packet had been sent off to Cigna. About a week later, I was so excited to see a letter in my mailbox from Cigna – until I opened it. The letter stated that medical necessity could not be established until I provided 6 MORE MONTHS of documentation of medically-supervised weight loss attempts. I provided almost a year of physician-supervised weight loss attempts, and they wanted 6 more. Jerks.

I was frustrated because I had started telling family and friends that I was preparing for surgery, I had money set aside, and was expecting to be on the operating table in about a month.

I went through a bit of a mourning period after that. I was so upset that my insurance wanted to postpone a surgery that was already “medically necessary” by every other means, except more paperwork. They questioned my 8 months of records from Weight Watchers as not sufficient, when their website specifically outlines Weight Watchers as a suitable weight loss method, when supervised by a physician. I met with Dr. Poor, my primary care doctor, who said that St. Mark’s Hospital offered a physician-assisted plan through his partner clinic, Lone Peak Family Medicine. I took the information flier, called up the registration line, and had an appointment for the clinic later in the week.

When I went in for my appointment, I was surprised to find that Dr. David Jack was the supervising physician of the program. Dr. Jack and I go back quite a while…he was the doctor who supervised me on my treatment on Phen/Fen back in 1995-1997. He also managed my care for several years after my treatment of ARDS. We went over my more recent health history, set up a very-low fat food plan, and I began on medication for weight loss.

Unfortunately, I didn’t have a significant loss of weight in the time he supervised my weight loss. I went down about 15 pounds in 6 months, which isn’t very significant when I have almost 200 pounds to lose. He agreed that weight loss surgery was a good option, wrote a letter indicating his support of surgery, and forwarded it to my primary care doctor.

In early October, I’d hit my 6 month mark. Dr. Poor wrote another letter for Cigna, again emphasizing the need to expeditiously approve my surgery. Unfortunately, the appeals process with Cigna went on for THREE FULL MONTHS. They kept sending me letters saying that they could not determine medical necessity, even though the needed paperwork had been received. Apparently, they had a really hard time matching up my original surgery packet and my updated paperwork….which were scanned into the same computer system. Yay, technology!

In early January, Kristina (who was my valiant pre-authorization ally through those 3 months) was told to resubmit the entire packet to Cigna. Within two weeks, I FINALLY had the approval for surgery! This was last Monday, and since then I’ve had my surgery date scheduled and began this blog.

I don’t know how many people go through a 13-month approval process for their insurance, especially when all clinical criteria for medical necessity is obvious. It was documentation not being exactly how the insurance authorization team wanted, then many other glitches in the system. But now my surgery is approved, and I meet with Dr Smith again for a pre-surgical appointment tomorrow. Also, my pre-surgery “crash diet” begins.

For those interested in the specific verbiage of Cigna’s 2012 weight loss surgery policy, at the time I went through the process, the criteria is as follows:

CIGNA covers bariatric surgery using a covered procedure outlined below as medically necessary when ALL of the following criteria are met:

The individual is ≥ 18 years of age or has reached full expected skeletal growth AND has evidence of BMI (Body Mass Index) ≥ 40 OR BMI 35–39.9 with at least one clinically significant obesity-related comorbidity, including but not limited to the following:

  • mechanical arthropathy in a weight-bearing joint
  • type 2 diabetes mellitus
  • poorly controlled hypertension 
  • hyperlipidemia 
  • coronary artery disease 
  • lower extremity lymphatic or venous obstruction 
  • severe obstructive sleep apnea 
  • pulmonary hypertension

Failure of medical management including evidence of active participation within the last two years in a weight-management program that is supervised either by a physician or a registered dietician for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of ALL of the following components: weight, current dietary program, physical activity (e.g., exercise program)

A thorough multidisciplinary evaluation within the previous 12 months which includes the following:

  • an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s) and all of the associated current CPT codes 
  • a separate medical evaluation from a physician other than the surgeon recommending surgery, that includes a medical clearance for bariatric surgery 
  • unequivocal clearance for bariatric surgery by a mental health provider 
  • a nutritional evaluation by a physician or registered dietician

2013 Update: Cigna has made three separate major changes to the verbiage of their bariatric surgery guidelines since my surgery was approved. Even if it doesn’t seem like the documentation of the 6 months of medically-supervised weight loss is such a sticky point, it is. Three other weight loss surgery patients have contacted me to say they had the same denial for medical documentation of the six months of supervised weight loss. Make sure to document EVERYTHING if you’re considering weight loss surgery, especially if you’re insured by Cigna!

Comments

  1. Great things come to those who wait, right?

  2. Cigna has now up dated the policy: as of Effective Date……………………….3/15/2012
    Medical management including evidence of active participation within the last 12 months in a weight-management program that is supervised either by a physician or a registered dietician for a minimum of three consecutive months. The weight-management program must include monthly documentation of ALL of the following components:
     weight
     current dietary program
     physical activity (e.g., exercise program)
    Programs such as Weight Watchers®, Jenny Craig® and Optifast® are acceptable alternatives if done in conjunction with the supervision of a physician or registered dietician and detailed documentation of participation is available for review. However, physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.
    • A thorough multidisciplinary evaluation within the previous six months which includes ALL of the following:
     an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s) and all of the associated current CPT codes
     a separate medical evaluation from a physician other than the requesting surgeon that includes both a recommendation for bariatric surgery as well as a medical clearance for surgery
     unequivocal clearance for bariatric surgery by a mental health provider
     a nutritional evaluation by a physician or registered dietician
    Bariatric Surgery

  3. For Cigna requirements of bariatric survey, you are required to go through a 3 month period of Dr supervised weight management care. What is Cigna looking for? Is it expected that I lose weight and so I would drop my BMI under 40 during the 3 month period? If I drop, will they approve surgery still?

  4. My 2013 CIGNA plan is different,
    1. Clinical records support a body mass index (BMI) of 40 or greater, or 35 or greater with high-risk comorbid conditions such as serious cardiopulmonary problems or severe diabetes mellitus.
    2. Diagnosis of morbid obesity for a period of two years prior to surgery.
    3. There is no treatable metabolic cause for the obesity.
    4. The patient has participated in a physician-supervised weight-loss program, of at least six months duration, that includes dietary therapy, physical activity and behavior modification. This physician-supervised program must be documented in the medical records. Surgery must occur within six months of completion of the physician-supervised weight-loss program.
    5. A repeat or revised bariatric surgical procedure is covered only when medically necessary or a complication has occurred, such as a fistula, obstruction, or disruption of a suture/staple line.
    6. The patient is age 18 or older.
    7. A psychological evaluation has been completed and the patient has been recommended for bariatric surgery.
    8. Patient has not smoked in the six months prior to surgery.
    9. Patient has not been treated for substance abuse for one year prior to surgery.

    So I’m unsure about this physician-supervised weight loss program requirements. It doesn’t state if I have to visit the doctor each month or if attending my weight watchers meeting will be enough. Oh, and I didn’t go the entire month of January because it is so packed in the meetings I didn’t want to fight for a seat with the new year crowd. Maybe I should have started this much earlier. :/

    • Be careful! And don’t set yourself up to get it approved the first time. #4 on Cigna’s list is the physician-supervised diet. You MUST document EVERYTHING! Every weigh in. Every doctor’s visit.

      I had almost monthly doctors visits for weight-related comorbidities in the year leading up to surgery, which I kept my own records for, AND included all my records for seven months of Weight Watchers. And my case was denied by Cigna for not having 6 months of physician-supervised weight loss. It was semantics, I appealed it, and they still made me do 6 more months of supervised weight loss with a bariatric specialty doctor. Did that from April to October, and did 2 more appeals before it was finally approved 3 months later in January.

      It sucks, but be prepared! Hopefully you won’t have such a difficult process.

  5. Thank you for sharing. Cigna jammed up my coworker’s back surgery for a congenital defect, so I assumed cigna would be difficult for bariatric surgery. So, thank you for the information.

  6. Sunshine says:

    I am awaiting on Cigna approval my paper wrk was foward to the nurse I was told on yesterday my paper wrk was faxed to Cigna on 4/29/2013 fingers crossed.. My surgeon office wonldnt fax anything until I completed EVERYTHING so that would less the chance for denial.. As soon as I hear I will post… Oh and I call Cigna EVERY DAY!! You have the right as a member!!! :)

    • optimistic_k says:

      Sunshine, was yours approved? My paperwork was sent yesterday and I want to know if yours was approved or denied first time around so I can be prepared for denial etc. Thanks!

  7. I hate Cigna…I completed 6 months of managed weight loss, letter of recommendation from cardiologist,records from nutritionalist and primary,ekg,egd and stress test and they denied me. They said my weight loss history was incomplete and a code was incorrect. I really feel like they’re giving me the run around. because my company will be leaving Cigna in less than 30 days. I will appeal

  8. Diamondndu says:

    I am with Cigna also and have been getting the runaround since last March. Completely denied at first because my hospital was not a “National Center for Excellence” so I traveled 12 hours to one and set everything up there. Then It was documentation, today I had faxed referral from my primary Dr. and dietitian reports. Waiting to see what they will need tomorrow.

  9. Brenda Fletcher says:

    It is now Dec. 13 and Cigna is still giving me nothing but a run around.

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