CIGNA PPO Experience?

[Guest guest]

Hi All,

I am awaiting my second try at predetermination of benefits with

Cigna PPO. The first application, (for Lap RNY), was turned down as

not medically neccesary due to " experimental " nature of the

procedure.

Now I am applying for the DS, under CPTs 43843 and 43633 by Dr.

Elariny in Fairfax VA. Does anyone have experience with CIGNA PPO for

the DS procedure? Did you use the same CPT codes?

Any experience or advice with anything I've mentoined here would be

greatly appreciated!

Best Regards,

[Guest guest]

> Hi All,

>

> I am awaiting my second try at predetermination of benefits with

> Cigna PPO. The first application, (for Lap RNY), was turned down as

> not medically neccesary due to " experimental " nature of the

> procedure.

>

> Now I am applying for the DS, under CPTs 43843 and 43633 by Dr.

> Elariny in Fairfax VA. Does anyone have experience with CIGNA PPO

for

> the DS procedure? Did you use the same CPT codes?

They are calling Lap RNY experimental???

I had the DS in Feb, and I am Cigna PPO. I was HMO, and could not get

a consult with the surgeon that I wanted (Dr Anthone). They did set

me up with an appointment with a local RNY doctor (which I

cancelled). I then switched to PPO and did not have any trouble

getting approved for the DS.

I'm still at work right now, and can't remember the codes that were

used, but i'll look when I get home and send them to you.

Mostly my experience with Cigna was that you have to call multiple

times. I was also referred by my HR department to their Cigna

contact - their salesperson! Although I don't think that she could

have helped with the actual approval, she was the only person who

gave me straght answers, could find out where my paperwork was, and

what part of the approval process it was still in.

Ellen

DS 2/14/01 310

Dr. Anthone

5/30/01 251

- 59 lbs

[Guest guest]

Thanks Ellen. I did not appeal the " experimental " Lap RNY decision,

instead I re-applied for the BPD/DS with another surgeon. Got my fingers

crossed. If they turn this down, I will appeal, sue, whatever it takes.

stellen@... wrote:

>

>

> > Hi All,

> >

> > I am awaiting my second try at predetermination of benefits with

> > Cigna PPO. The first application, (for Lap RNY), was turned down as

> > not medically neccesary due to " experimental " nature of the

> > procedure.

> >

> > Now I am applying for the DS, under CPTs 43843 and 43633 by Dr.

> > Elariny in Fairfax VA. Does anyone have experience with CIGNA PPO

> for

> > the DS procedure? Did you use the same CPT codes?

>

> They are calling Lap RNY experimental???

> I had the DS in Feb, and I am Cigna PPO. I was HMO, and could not get

> a consult with the surgeon that I wanted (Dr Anthone). They did set

> me up with an appointment with a local RNY doctor (which I

> cancelled). I then switched to PPO and did not have any trouble

> getting approved for the DS.

> I'm still at work right now, and can't remember the codes that were

> used, but i'll look when I get home and send them to you.

> Mostly my experience with Cigna was that you have to call multiple

> times. I was also referred by my HR department to their Cigna

> contact - their salesperson! Although I don't think that she could

> have helped with the actual approval, she was the only person who

> gave me straght answers, could find out where my paperwork was, and

> what part of the approval process it was still in.

> Ellen

> DS 2/14/01 310

> Dr. Anthone

> 5/30/01 251

> - 59 lbs

>

> ----------------------------------------------------------------------

>

[Guest guest]

,

My experience with Cigna PPO;

Cigna told me they had no record of a fax with my Letter of Medical

Necessity (LOMN) being sent by my Drs. office. Meanwhile the Drs.

office had sent me a copy of what they sent to Cigna, so I knew it

was sent. This seems to be a typical runaround/delay tactic with

their hoping people will give up with frustration I think.

Since I had to have the DRS. office resend my LOMN, I wanted to make

sure they included the necessary details so I asked Cigna again for

them to tell me what the criteria was for LOMN. (I had gotten

incomplete information initially).

They told me there was no criteria (typical Ins Co. answer to those

who don't persist), I said I knew there was because Cigna told me

what it was the last time I called as they looked it up and read if

off the screen to me. They of course had " no record " of me calling.

(another tactic) I responded with " then how did I know the fax number

to use as its not on your ID card, how did I know to send a letter of

PREDETERMINATION with LOMN and not pre authorization or pre

certification in the first place if you didn't tell me?

Note: PREDETERMINATION is different that pre authorization, or pre

certification, because LOMN is needed, a PREDETERMINATION is needed

in addition to the pre authorization which is obtained by the DR

prior to surgery.

They supposedly looked it up and asked a supervisor who said there

was no criteria. Note: Three different people in the same phone call

said there was no criteria for LOMN for gastric bypass. They were

all wrong.

Cigna didn't give me the criteria until I pressed in again gave them

the CPT procedure codes and then quoted this to them:

" California Health & Safety Code section 1363.5 mandates access to

these criteria including identification of the authors of the

criteria, the clinical principles utilized to develop the criteria,

the last time it was reviewed and updated, etc. "

Miraculously they found it.

Some insurers refuse to provide access to the criteria for medical

necessity, even when denials are based on failures to

meet " criteria. " Ask how anyone can successfully challenge such a

denial without access to the criteria and background information upon

which it is based.

Insurers have these tricks to put obstacles in your way... once you

know about them you can get around them. Please learn from this:

1) Each time you phone Cigna ... the very first thing you want to do

is ask for the person's name that you are talking to , their

extension number and their desk number. This serves two purposes..

you can document this and have this as a reference if you need it and

it puts them on notice that you aren't going to be easily fooled like

most of us who call in and don't know the score.

2) At the onset of your phone call... REQUEST THAT THIS PHONE CALL BE

LOGGED. They are supposed to any way.. but I have found they don't.

If its not logged, it didn't happen. That's why your documentation of

the event with their name and number helps support you and what you

say.... and again it puts them on notice that you know the ropes.

3) Ask for the fax number to send a LOMN/ PREDETERMINATION that your

DR can use to send info so you don't have to wait for snail mail back

and forth. Note well: this is not the same number for pre

authorization, make it clear you are not asking for the fax number

for pre authorization.

4) Once your Drs. office has sent in your predetermination request to

a particular person....DO NOT ASSUME CIGNA WILL ADMIT THAT ITS BEEN

RECEIVED!!!! Quite often when the patient checks, Cigna says they

never received the fax.

**That its why its doubly important for you to have gotten a person's

name, desk number and extension so that you can FAX IT

TO " ATTENTION ... " ... otherwise they stay in a pile and on one takes

any action on them and claim it wasn't received.** So when you give

the Fax number to the DR's office include : ATTENTION TO: any Cigna

persons name, ext #, desk #.

5) If you end up having to have the Drs. office resend the fax

because Cigna said it wasn't received ... Call your Drs. office and

have it resent and find out when they are going to do it... then

call your Cigna contact person back and let them know the fax is on

its way.... and REQUEST THAT THEY NOTIFY YOU ITS BEEN RECEIVED. Make

sure you get a name, ext and desk #, ask that your call be logged.

6) Don't ASSUME either that just because they said its been received

that its been logged into your file! You have to call back and ask

them if its been put into the system. Again make sure you get a name,

ext and desk # right off the bat, ask that your call be logged so

they know you are serious.... once they confirm its in the system

then the predetermination request including your LOMN goes to a

medical review board... mine took 2 days from confirmation that the

fax was received, and logged into the system to day of approval.

I have Cigna **PPO** and the conact info is for Chattanooga, TN

thiere headquarters so what applies here may not apply to the other

designation like Cigna HMO or anything that might be particular to

your CO's policy....

_________________

I didn't get a **preAuthorization** ... I needed to get what Cigna

called **preDetermination** that's an important difference.

The first thing I did was to call Cigna and tell them I was expecting

to have GASTRIC BYPASS SURGERY for Morbid Obesity. Do not say Weight

Loss Surgery.

Do not say obesity... SAY MORBID OBESITY... there is a medical

difference between the two and that is what they try to catch you on.

They should tell you that the surgery is only covered when there is a

medical necessity. .. and that you need a predetermination letter of

medical necessity... so your request must include a LOMN (Letter of

Medical Necessity).

I have PPO so I didn't need a referral from a PCP. So my surgeon's

office wrote the LOMN for Predetermination.

I then asked what their criteria was for medical necessity.They don't

want to tell you this, you have to be persistent. They will tell you

none exits do not take no for an answer. Ask them to look it up. They

will say there is none. ask them to ask their supervisor... be

persistent. If they still refuse ask them to check further.

Avoid all this by saying to them: " Please look up this procedure

under CODE NUMBER: 43847 Distal Gastric Bypass " ...they should be

able to find it under that code and ask for the criteria for LOMN.

Some insurers refuse to provide access to the criteria for medical

necessity, even when denials are based on failures to

meet " criteria. " Ask how anyone can successfully challenge such a

denial without access to the criteria and background information upon

which it is based.

I had asked this question on Cigna's internet site.. not easy to get

to the place where you can email them.. they do not make it easy...

this is what they sent me which ended up to be wrong and was not the

criteria they used... if they had used it I wouldn't have gotten

approved. I suggest this is not what Cigna PPO used as criteria, but

it may well be what Cigna HMO uses:

" Thank you for your inquiry about the medical necessity criteria for

gastric bypass surgery. Here are some facts about how the condition

is evaluated:

The Body Mass Index (BMI) is an objective measurement, which is

currently considered the most accurate measurement of excess adipose

(fat) tissue.

The National Institute of Health defines obesity as a BMI of greater

than 27.5kg, and severe or morbid obesity as greater than 40kg. A

comorbid condition occurs when another part of the body becomes

diseased as a result of the morbid obesity. Examples include:

hypertension, gastric reflux,diabetes mellitus, coronary artery

disease, pulmonary dysfunction, severe sleep apnea, lower extremity

venous and lymphatic obstruction, obesity related pulmonary

hypertension, symptomatic osteoarthritis of the knee, hip, or back.

Gastric bypass surgery is considered medically necessary and will be

covered under the terms of your benefit plan if all of these criteria

are met:

BMI

Greater than 40kg for at least five years, or Between 35-40kg with

additional documentation of one or more clinically significant

comorbidities that have failed to respond to non-surgical treatment,

including appropriate and adequate medication.

Previous Weight Loss Attempts

In addition to the minimum weight requirements, you must submit

documentation supporting previous weight loss attempts. The patient

must have actively participated and reasonably complied in at least

three professionally supervised weight loss programs for a minimum of

twelve weeks in each program. At least one of these programs should

have included weigh-ins on a regular basis.

Age and Risk

The patient must be an acceptable age and risk for surgery. This is

determined by your physician.

Comorbidities

The medical records should indicate that your physician has made

efforts to treat any comorbidities using standard conservative

protocols.

It's important you know that the referring physician must receive pre-

authorization through CIGNA's Health Services Department by

submitting clinical information supporting all of the above medical

necessity criteria.

Please contact your physician to discuss possible treatment plans. If

the physician feels that surgery may be necessary and that you meet

the above criteria, he or she can contact the Medical Review

Department to start the pre-authorization process.

In addition, please know CIGNA HealthCare does not guarantee or

represent that any particular benefits will be paid. Payment is based

on the terms of the group plan and the patient must be eligible when

receiving treatment.

Sincerely,

Internet Customer Service Team

CIGNA HealthCare

www.cigna.com "

________________________________________________

This is what I was finally able to pry out of them by phone, and this

IS what Cigna PPO used for my approval. The pre determination request

for gastric bypass needed to include the Letter of Medical Necessity

(LOMN) whose criteria included:

History

Physical

Height

Weight

Frame Size

Recent Labs

Blood Pressure

Medicines

Treatment Plan

Prognosis

Note... no mention of detailed diet history containing 3 medically

supervised weight loss programs in the last five years as the info

from a query to the generic Cigna site said.

This is the fax number the told me to use for sending in the

predetermination.... Make sure you ask for the phone number as

preauthorization's don't go to the same place as predetermination. It

may be different for your plan:

Cigna PPO FAX :

you need to get a person's name and desk number and extension number

and ask that the call be logged every time!

Here are the codes used in my request for approval:

CPT Codes:

Distal Gastric Bypass 43847

Parietal Gastrectomy 43638-51

Cholecystectomy 47605-51 (gall bladder removal)

ICD9 Diagnostic code: Morbid Obesity 278.01

Hope this helps! Remember many Insurance CO's use tactics to get you

frustrated and hope you will give up! Don't Give UP!

Last word of advice - if pushed, you can say " I intend to

aggressively pursue this with any means at my disposal including the

legal help of the Obesity Law and Advocacy Center "

http://obesitylaw.com/

mary bmi 68

corona, ca

pre op 6/27/01 dr rabkin

cigna ppo

[Guest guest]

>

>

> My experience with Cigna PPO;

- thanks for taking the time to put together such detailed and

helpful Cigna information. I am post-op now, but I so wish that I had

known all this when I was getting the Cigna run around - it would

have been so helpful. I experienced many of the same things that you

did, including misrouted paperwork, incorrect phone and fax numbers,

etc. It also took me awhile, after getting different information from

every person, the difference between pre-D and pre-A. Once I finally

got that clarified, I " found " that my paperwork was in the

Bourbonnais, Il office, where pre-D's are approved or denied. They,

however, refused to give me a number to that office - just the 800

number, no matter how much of a stink i made. Luckily, once it got to

that office, i was approved in a matter of days.

However, I now have that phone number, since they helpfully included

it on the approval letter that they sent me!!

Ellen

DS 2/14/01 310

Dr. Anthone

3/30/01 - 251

-59

>

[Guest guest]

" - thanks for taking the time to put together such detailed and

helpful Cigna information. I am post-op now, but I so wish that I had

known all this when I was getting the Cigna run around - it would

have been so helpful. "

I'd like to think it was an isolated experience, its not... I've

learned their tactics are similar in other ins co's too.. so I posted

something similar in the file section here for others to hopefully

learn from; insurance co tactics.

The decision to have WLS is hard enough without this battle with

greedy bureaucrats who's only interest is finding ways of not paying

your medical coverage.

How these employees stomach working for such companies I will never

know. Do they take in house classes on how to be obstructionist?!

mary bmi 68

corona, ca

pre op 6/27/01 dr rabkin

cigna ppo