just posted this on DS forum, too

[MamaShelia]

Hello ALL!

I haven't posted in almost exactly 2 months and a lot has happened in life! I will spare you all of it (a death in family, I lost a teacher on my team to depression--she just walked out of the building--and have been covering her classes as well as my own, I had a lupus crisis in November, and now I have had an allergic reaction to no one knows what, but I do so need to update you all before more time passes!)

Oct 7th: I had consult with Dr. Ayoola in TX. I have selected him as my surgeon for my revision to DS. I was very impressed with his knowledge base and bedside manner. I asked all types of questions about previous cases, how many DS's he had performed (too numerous to count) how many RNY to DS revisions --5!

Whoa, Nellie, did you say, 5?!?

Well, yes, Nellie, he did.

After much consideration and prayer my husband and I felt that we had rapport with him and that every surgeon on the preferred list had a patient who was their number SIX in order to get to the hundreds of patients that they have under their belts and we are willing to be his number 6. (I am driving 7.5 hours to get to AYOOLA)

So we are sticking with Dr. Ayoola.

So on OCT 9th, I had an EGD with him and he did not find a "mini bypass" but he did find that the limbs were not the lengths that original surgeon had described in the preoperative notes. I can't remember right now, but the one that Ayoola usually leaves a little longer, mine has been trimmed pretty short and the limb that he would have trimmed shorter was left longer. (Will get back to you....don't have my folder in front of me.)

Ayoola sent me home to get clearance from my cardiologist. I had a scheduled apt with him on Oct 23rd anyway and we scheduled a stress test for Nov 11th.

Got the results and the letter of clearance to Dr. A's office on Thanksgiving Monday and we are rolling right along.

Dr. A's staff sent in a pre certification request, CIGNA sent it back for more info...which we all had on file already (not sure why they didn't turn it all in art once) anyhow....all of our cards are on the table and I just got an email from AYOOLA's office manager tonight that he had received a letter of DENIAL...okay...poopy news, but expected, so...I am over it.

Actually I had called on Friday afternoon and found out and the person on the phone pulled the record for me, because a determination had not been posted yet and she told me I was denied for two reasons 1. I did not have proof of 90 days of nutritional/weight loss visits and 2. my BMI was less than 50 (I am at 45), she sounded very positive and said as soon as you complete your 90 days, the one will be taken care of and your doctor can call and speak directly to the medical reviewer and the other will be taken care of.

OKAY, back to today, when the office mgr emailed me about the denial, he said the letter states that I have not proven 2 years of compliance to the original post op diet, well there is NO WAY to do that. I saw Dr. Olchowski ONCE after my surgery for a 1week follow up and that is IT. He never required any more visits and now that he has lost his license, even that one visit cannot be retrieved.

So, QUESTION: How do I get CIGNA to understand that nothing from that time is able to be retrieved?

ANOTHER QUESTION: Was the CIGNA REP who answered the phone on Friday and read the reviewer's notes getting confused with 90 days of nut visits and 2 year's compliance, or have you guys seen cases where the 90 days can fill in for the 2 yrs post op if medical necessity is proven?

Office manager asked if I wanted to appeal, I said most definitely. Especially if all I need is 90 days nut (I am going to call CIGNA tomorrow and see which it is 90 days or 2 yrs post op to be sure, that side of the insurance office not open on weekends) and then a call from Dr. Ayoola to call in. Yes, I want to appeal!

NOW, THIRD QUESTION, when do I need to send in articles for BMIs under 50 can be just as successful with DS and letter from me and my personal circumstances and all of that?

Do, I do that through Dr. Ayoola's team or on my own?

Thanks for reading...any and all replies welcome!

Hugs,

Shelia

 

[southernlady]

Tagging @DianaCox and @Larra as they are our experts when it comes to insurance companies being stupid!

 

[Larra]

You need to get your Evidence of Coverage (EOC) and read for yourself exactly what the requirements are regarding the 90 day nutritional thing (which you will soon have covered) and this mysterious new requirement of proof of 2 years post-op compliance. Never heard that one before! Usually the insurer just issues a denial and says you were noncompliant without any justification for it.
Do NOT take the word of anyone over the phone interpreting your requirements. No one at that company cares about this as much as you do. Learn the requirements, and also your appeals rights, for yourself.
If there really is a specific 2 years compliance thing, I think your best bet is to 1) state that you were compliant and that they have no proof to the contracy on which to base a denial, and 2) show proof that your prior surgeon lost his licence and is gone and that no records are available to you, which is certainly not your doing. How well all this will fly, I don't know. Revision appeals are tricky.

But better yet, if a peer to peer consult is available to you, definitely have Dr. Ayoola do this. Warn him in advance that they are going to get fussy about the 2 years compliance business, and also about the bmi. You don't lose any other appeals rights by going through this step, and sometimes it does work.

 

[DianaCox]

What Lorraine said. In addition, I would call Cigna and ask them for evidence of their criteria for revision. I doubt very much if they can give it to you, and I suspect that they are making it up. And even if they are not, you have the right to question the policy. You can also point them to this: http://asmbs.org/resources/systematic-review-on-reoperative

 

[Charris]

I was told by dr staff that I would be denied because I had Cigna and a bmi of 45 it had to be 50. I initially got denied because they said I was non compliant with the post op diet. I had the weight loss clinic send in my file showing I had been going to them for 7 years and was denied and approved in a 3 day time period. But the Bmi being too low was not the reason. I had Cigna PPO at that time.

 

[Dawn]

To be completely honest I had that exact same thought process about being a DR number 6 and they all have to start somewhere. It back fired horribly on me. I really hope when you get insurance all worked out the rest is smooth sailing and your experience will be much better then mine.

 

[MamaShelia]

Tagging @DianaCox and @Larra as they are our experts when it comes to insurance companies being stupid!

Thanks for the clean up, Southern Lady!

 

[MamaShelia]

You need to get your Evidence of Coverage (EOC) and read for yourself exactly what the requirements are regarding the 90 day nutritional thing (which you will soon have covered) and this mysterious new requirement of proof of 2 years post-op compliance. Never heard that one before! Usually the insurer just issues a denial and says you were noncompliant without any justification for it.
Do NOT take the word of anyone over the phone interpreting your requirements. No one at that company cares about this as much as you do. Learn the requirements, and also your appeals rights, for yourself.
If there really is a specific 2 years compliance thing, I think your best bet is to 1) state that you were compliant and that they have no proof to the contracy on which to base a denial, and 2) show proof that your prior surgeon lost his licence and is gone and that no records are available to you, which is certainly not your doing. How well all this will fly, I don't know. Revision appeals are tricky.

But better yet, if a peer to peer consult is available to you, definitely have Dr. Ayoola do this. Warn him in advance that they are going to get fussy about the 2 years compliance business, and also about the bmi. You don't lose any other appeals rights by going through this step, and sometimes it does work.

Okay, Larra, I have read the CIGNA requirements for revision, that is posted online, is that different from my EOC?

Yes, I could not get anyone to talk to me today, was on hold after work for over 30 minutes twice!

I still didn't receive my denial letter today, but here is the portion of it from the copy the doc's office sent to me: (see below)

Okay, now here is another hitch, if this is NOT done during my school break for Christmas (19-Jan 6) then I HAVE to wait till summer break! So, if I fight and won now, will my approval still be valid in June!?

 

[MamaShelia]

I think the doc's office may be reading into it and saying 2 yr compliance, because maybe that is for other insurances??? But I mean, how can they argue that those records are no longer available?! They can't! SO, if they now want me to do a 90 day nut workup....(which is under the original requirements for all newbie WLS for CIGNA, but is not a part of the revisions requirements) in lieu of not having the original compliance records (not my fault) then okay, I am not TOTALLY against that, but that's what I want to know....from CIGNA's mouth!

 

[MamaShelia]

So, Larra, what do you suggest for next steps?

I think I need to speak to someone in the reviewer's office to explain EXACTLY what they want form me.

Not worried about BMI....need to get this other mess cleared up.

Thanks, girl!

 

[MamaShelia]

What Lorraine said. In addition, I would call Cigna and ask them for evidence of their criteria for revision. I doubt very much if they can give it to you, and I suspect that they are making it up. And even if they are not, you have the right to question the policy. You can also point them to this: http://asmbs.org/resources/systematic-review-on-reoperative

Got the article bookmarked, Diana, thanks!

 

[Larra]

@MamaShelia I think I will let @DianaCox answer the questions about your insurance from here, though we may all need more info. I have no idea if what you are seeing online is the same as your EOC. And I don't know whether they can substitute a non-revision requirement for a revision requirement.
The one thing that seems clear from what you provided is that a peer-to-peer is permitted as one part of your appeals rights. I strongly recommend that you have Dr. Ayoola give this his best shot.

 

[MamaShelia]

I was told by dr staff that I would be denied because I had Cigna and a bmi of 45 it had to be 50. I initially got denied because they said I was non compliant with the post op diet. I had the weight loss clinic send in my file showing I had been going to them for 7 years and was denied and approved in a 3 day time period. But the Bmi being too low was not the reason. I had Cigna PPO at that time.

Hey Charris,


Thanks for chiming in!

I actually have CIGNA CHOICE FUND HRA, which is the only coverage our school has for bariatric or fertility treatments--have no problem with one, and the other just can't get right! =0)

Unfortunately I have not been going to anyone for that long, the last I had WW was in 2013, for about 7-8 months. Just off again, on again type stuff, before and since.....

Like I said, I will do the 90 day nut., especially if it gets me a summer date now, because I am getting afraid we are cutting it too close for a winter break procedure and for me to up and about and handle my high schoolers.

Because of high-stakes testing, we are not "allowed" excessive time off during the spring break time frame. Save that fight for another day. Especially with this being a revision, I want to have all the healing time that I can.

 

[MamaShelia]

To be completely honest I had that exact same thought process about being a DR number 6 and they all have to start somewhere. It back fired horribly on me. I really hope when you get insurance all worked out the rest is smooth sailing and your experience will be much better then mine.

Yikes, Dawn, I am sorry to hear that!

Did you want a DS and are getting the second part later ? Or is a sleeve want you wanted? I see you are a newbie sleeve....how are you doing?????

 

[MamaShelia]

@MamaShelia I think I will let @DianaCox answer the questions about your insurance from here, though we may all need more info. I have no idea if what you are seeing online is the same as your EOC. And I don't know whether they can substitute a non-revision requirement for a revision requirement.
The one thing that seems clear from what you provided is that a peer-to-peer is permitted as one part of your appeals rights. I strongly recommend that you have Dr. Ayoola give this his best shot.

Okay! Sounds like a plan.

https://cignaforhcp.cigna.com/publi...overagepositioncriteria_bariatric_surgery.pdf

Please copy and paste the link above...that is what is online and what the customer service reps quote from when talking to me on the phone.