CIGNA Denial Overturned - A Revision Case Study

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Bariatric Insurance Denial Overturned – A Revision Case Study

 

       Patients (like me) who have had a successful outcome with their first weight loss surgery, only to re-gain weight years down the road, are often particularly difficult for providers to get approved for a revision or conversion.  We handle a great many of these cases and believe our success in getting insurance coverage is key to people continuing on their road to better health.  Here’s a great example.

       Our office represented this 55 year old woman seeking a revision from an adjustable gastric band placed in 2004 when her BMI was over 52.  She successfully lost well over 100 lbs., getting her BMI into the low 30’s, when she began to regain weight and experience a return of her co-morbid conditions, including sleep apnea.  While a precise anatomical problem could not be confirmed despite several different diagnostic tests, she began to experience intolerance to her gastric band and it was decided it needed to be removed and that conversion to a RNY was medically necessary.  She did have bariatric surgery coverage under her plan.

Her surgeon sought pre-authorization from CIGNA in early 2012 seeking to remove the gastric band and perform the RNY gastric bypass. CIGNA denied the request on the grounds the treatment was not medically necessary, that there was no “technical failure” of the gastric band and that the patient was not compliant post-operatively.  DOES THIS SOUND FAMILIAR BECAUSE IT IS THE SAME SONG & DANCE EVERY INSURANCE COMPANY TRIES TO USE TO DENY REVISIONS, NO MATTER WHAT THE FIRST OR SECOND PROCEDURES ARE – – BLAME THE PATIENT!

    The surgeon’s office appealed but really didn’t provide much more information than what was in the pre-authorization request.  That’s not unusual – surgeons are great at doing surgery!  CIGNA (big surprise) denied that first level appeal but fortunately the patient found out about our office and retained us to assist her through the remainder of the appeals process.  We presented a very comprehensive picture of her history, participated in a level 2 appeal  hearing with CIGNA to amplify all the reasons why their decision was wrong, and just CIGNA has now overturned the denials of the explant and the RNY conversion and the result is one ECSTATIC PATIENT and a surgeon’s office happy to be able to provide the care believed to be necessary for their patient.

ALL TOO OFTEN PATIENTS AND PROVIDERS BOTH SHY AWAY FROM THE CHALLENGES PRESENTED BY DIFFICULT REVISION AND CONVERSION CASES.
PLEASE ALWAYS KNOW THAT WE CAN HELP! [

601-C East Palomar Street #480 Chula Vista, California 91911 Tel - 877-992-7732 Fax - 844-384-9199

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