just posted this on DS forum, too

[Charris]

Ok well if you provide the 7 to 8 months of ww you still need the nut visits? I only had to do 1 nut visit.

 

[Larra]

These requirements are very confusing. First, though, there is no statement of proving compliance for the first 2 years. The 2 year thing is something about a technical failure leading to the patient not losing at least 50% of excess weight after at least 2 years, or something like that.
but what's really confusing is that they say "all" requirements" must be met, and one of the requirements is technical failure of the operation, such as pouch enlargement. Does this mean that no one will be approved in the absence of technical failure??

Of course they also don't seem to understand that pouch enlargement is not usually the culprit, but rather enlargement of the stoma.

I think Dr. Ayoola can argue that for someone with a failed gastric bypass, the only effective revision is to DS, regardless of your bmi being below 50. But whether they will get picky about the compliance stuff, I don't know. In theory, they can refuse everyone because how can anyone really prove compliance?

So get the peer-to-peer going, and find out everything you can about your appeals rights, because the peer-to-peer may not work.

 

[DianaCox]

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.

Cigna covers revision of a previous bariatric surgical procedure or conversion to another medically
necessary procedure due to inadequate weight loss as medically necessary when ALL of the following
are met:

• Coverage for bariatric surgery is available under the individual’s current health benefit plan.​

• There is evidence of full compliance with the previously prescribed postoperative dietary and exercise
program.
• Due to a technical failure of the original bariatric surgical procedure (e.g., pouch dilatation) documented
on either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD), the individual has
failed to achieve adequate weight loss, which is defined as failure to lose at least 50% of excess body
weight or failure to achieve body weight to within 30% of ideal body weight at least two years following
the original surgery.
• The requested procedure is a regularly covered bariatric surgery (see above for specific procedures).
NOTE: Inadequate weight loss due to individual noncompliance with postoperative nutrition and
exercise recommendations is not a medically necessary indication for revision or
conversion surgery and is not covered by Cigna.

OK, the "e.g." can include some OTHER technical failure, like stoma dilation. But STUPIDLY (well, not stupid if you're the insco not wanting to pay for a revision), it doesn't include failure because the surgery was inadequate to overcome your metabolic derangements - this is inappropriate. Picking the wrong surgery for you was your prior surgeon's fault, not yours.

There are NO additional requirements for 2 years or 90 days or anything in the posted bariatric policy, and therefore, there is no legal reason to impose additional requirements. Dr. Ayoola should argue in the peer-to-peer that your revision is MEDICALLY NECESSARY, that the requirement for "evidence of full compliance with the previously prescribed postoperative dietary and exercise program" is utterly meaningless and unattainable, in particular in view of the failure of your prior surgeon to maintain records, which means that this requirement can only be interpreted to mean that the burden is on the insurance company to provide "evidence of complete NON-COMPLIANCE" with the previously prescribed postop dietary and exercise program. The requirement as written essentially and impossibly requires you to prove a negative, which is that you never did anything wrong.

 

[robs477]

@DianaCox ......Holy Crap you are sooo good!!!! I'm so proud of myself because that's exactly what I thought after I read it too!!! In my ever so humble lay persons opinion of course…lol. I knew it looked familiar to me because that’s the same coverage .pdf…Cigna Coverage Policy Number ......0051, that I have.

 

[Larra]

Now that I think about it even a little more, I wonder if Dr. Ayoola could also argue that your original surgeon did not do your prior surgery properly in some way. After all, there had to be some reason that he lost his license. Was he found to be incompetent? Is there any evidence from upper GI x-rays or upper endoscopy that you have a gastric bypass that wasn't done right? That would be very helpful.