Comments on: The Surgery Approval Process

By: Sunshine

Sunshine — Thu, 09 May 2013 02:13:21 +0000

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!!!

By: Shelly

Shelly — Tue, 19 Feb 2013 11:16:07 +0000

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.

By: Nicole

Nicole — Mon, 11 Feb 2013 00:57:04 +0000

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.

By: Jan

Jan — Sat, 09 Feb 2013 19:40:59 +0000

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. :/

By: Patty

Patty — Wed, 01 Aug 2012 06:10:27 +0000

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?

By: Nicole

Nicole — Tue, 17 Jul 2012 20:02:46 +0000

Thanks for the update! I didn’t know that Cigna had changed the requirements.

By: sonya

sonya — Tue, 17 Jul 2012 20:00:53 +0000

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

By: Kathy

Kathy — Sun, 29 Jan 2012 22:06:23 +0000

Great things come to those who wait, right?