To get help with Insurance Denials for WLS/Revisions

Hi DianaCox and Larra . I was referred to this forum to help with an appeal process.

I was denied by Cigna because bariatric surgery isn't part of my employer benefits and I got a rejection later in the mail stating such. I'm finishing up a vacation but could post more information this weekend if you think there's a possibility of it helping. I CAN pay cash for my DS (already scheduled about 4 weeks from now) but I'd really love to appeal to insurance.

I'm currently 5'9" and just over 300lbs. I've tried several diets and workouts, was even dropped as a client by a paid fitness trainer. My BMI is around 46 if I recall, and have some comorbidities such as prediabetes and severe sleep apnea. My family has a history of severe heart disease and various cancers, so I'm hoping you can help me out here. Please let me know what other information I can send.
 
You need to obtain a copy of your Evidence of Coverage document (the insurance contract) from your employer, probably from HR. Not a summary of benefits - it should be around 100 pages long. We will need to see what that says.
 
Hi DianaCox and Larra . I was referred to this forum to help with an appeal process.

I was denied by Cigna because bariatric surgery isn't part of my employer benefits and I got a rejection later in the mail stating such. I'm finishing up a vacation but could post more information this weekend if you think there's a possibility of it helping. I CAN pay cash for my DS (already scheduled about 4 weeks from now) but I'd really love to appeal to insurance.

I'm currently 5'9" and just over 300lbs. I've tried several diets and workouts, was even dropped as a client by a paid fitness trainer. My BMI is around 46 if I recall, and have some comorbidities such as prediabetes and severe sleep apnea. My family has a history of severe heart disease and various cancers, so I'm hoping you can help me out here. Please let me know what other information I can send.

Excuse my language but these ladies know their shit! You're in good hands with them. We have been so blessed to have their wealth of knowledge willing and ABLE TO HELP US.
 
You need to obtain a copy of your Evidence of Coverage document (the insurance contract) from your employer, probably from HR. Not a summary of benefits - it should be around 100 pages long. We will need to see what that says.
Here you go. Pretty explicit about not covering surgery for weight loss even for morbid obesity. Hoping there might be a loophole I've missed.
 

Attachments

  • coloradocanuckbenefits.pdf
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DianaCox is the best at interpreting these documents, but as I understand it, you have to do an internal appeal first, if still denied you can proceed to external appeal. Since you have already received a denial, your right to appeal has been "vested", which means you can have the surgery and appeal afterwards, or file your appeal and go ahead with surgery while the appeal is being processed.
I read the section on page 37 where treatments for obesity, including morbid obesity, are excluded, and I'm assuming this is the basis of the denial. However, IMHO this section is not well written and seems to pertain more towards two things: treatments for altered physical appearance as a result of treatment of obesity (I guess this means plastic surgery to remove excess skin) and "weight loss programs or treatments", which sounds like Weight Watchers/Nutrisystem/ working with a nutritionist type of stuff. They don't specifically say that "bariatric surgery" or "weight loss surgery" is excluded. There is no question that you would meet medical necessity criteria - they didn't argue that you didn't - so you might as well take a shot at an appeal.
 
”...for medical and surgical services, initial and repeat, intended for the treatment or control of obesity including clinically severe (morbid) obesity, including: medical and surgical services to alter appearance or physical changes that are the result of any
surgery performed for the management of obesity or clinically severe (morbid) obesity.”

This unfortunately looks pretty clear to me is an exclusion. And that this is a shitty self-funded high deductible plan. Seriously, you might be time and money ahead to consider going to Mexico.

The only possibility is appealing the exclusion and asking your employer to pay for the surgery anyway. They have the power - though rarely the inclination - to overrule their own rules, since they are the payors.
 
I may have misspoke on the appeal being vested part (and surprised that DianaCox didn't correct me!). I think you have to file your initial appeal to be vested, and then, if you go ahead with the surgery, you can be reimbursed IF your appeal is successful.
However, I certainly agree that this is a self-funded plan and if they don't decide to pay for your surgery you are out of luck.
 
Yes, definitely appeal at least once to vest your right to appeal up the chain. Sometimes it requires two internal appeals (with insurance company) before you can go to external review (with your employer if it is a self-funded plan, though they may send it out to an external medical reviewing agency) or to the state if a fully-funded plan (which may also send it out to an external reviewing agency).
 

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