WINNING ON WEDNESDAY – Three takeaways coming from beating CIGNA and winning another bariatric surgery appeal

Every day is exciting when we get a payer’s denial overturned. Each case presents its own challenges. When cases are over, win or lose, they provide unique lessons we take away from the experience.  Today is another “WINNING WEDNESDAY” because we just found out we beat Cigna (again).  Whether you’re reading this as the patient who needs bariatric surgery, someone who loves that patient, or the provider committed to caring for the patient, there are at least three important lessons coming out of this experience that should be taken away for future benefit.

This patient’s situation just might sound familiar.  A middle-aged female patient was very successful losing weight and reducing her comorbidities after her LAP-BAND was implanted nearly a decade ago. She was a model patient.  Unfortunately, over time her weight loss success started to reverse itself and she began having problems, most notably suffering from severe GERD which did not respond to various attempted medical therapies or emptying the band. She was suffering from severe “band intolerance.”

Her surgeon requested preauthorization for (1) removal of the band; and (2) conversion to laparoscopic gastric bypass, a very common treatment plan for a great many patients. Just as common is the insurer’s response:  at first Cigna balked at even approving the removal of the band despite the obvious need.  A peer-to-peer review led them to approving the band’s removal, but they continued to deny the conversion to gastric bypass.  We see this idiocy all the time (unfortunately).  The reasons Cigna conjured about to support their claim of  “medical necessity” not being met were:

  1. A “technical failure” of the band, as defined by Cigna, was not established to their satisfaction;

  2. Without a technical failure the patient did not meet Cigna’s criteria for reoperative bariatric surgery; and lastly,

  3. There was no evidence the patient was compliant with her postoperative diet and exercise regime [Translation: IT WAS HER FAULT!]

So what happened? First, her surgeon’s office strongly recommended that she contact us so we could analyze the situation and determine if we could help her  appeal the denial.  We could, she wanted the help and so we jumped right in.  Twice Cigna denied the internal appeals we filed.  That wasn’t entirely unexpected.  All the time we were positioning the case to be ultimately decided via the powerful process of having a physician perform an independent, external review (also known as an IRO).  Once the case was out of Cigna’s hands our client’s chances of approval skyrocketed.  So what happened?

We won and Cigna lost.  Life is good.

Let’s look at three takeaways arising from this patient’s success:

TAKEAWAY #1:  YOU ARE NOT “STUCK” WITH EITHER THE PAYER’S BOGUS DECISION OR THEIR OUTRAGEOUS MEDICAL CRITERIA!

This bariatric surgeon’s office got it right.  We have all seen insurance company medical policies which make us cringe because they are so discriminatory against persons who need bariatric surgery.  So often they are wayyyy out of step with established clinical standards.  An important takeaway from this case is to not get caught up in whether the patient meets their criteria.  That’s what happened when the surgeon’s office made the preauthorization request, despite knowing this patient did not meet the nit-picky and highly suspect Cigna criteria for bariatric revisions and conversions.

Too many bariatric programs don’t even get their patients “in the game” because they see that the plan’s medical policy isn’t met and they feel defeated from the outset. Walking away is never the best way to go.  It’s always best if the focus stays on pursuing the most appropriate treatment plan, regardless of payer medical policy limitations.  Patients and providers should never panic if the four corners of a payer medical policy cannot be met. Submitting an excellent preauthorization request is what is most important.  If that request is denied, fighting the denial becomes the only way a patient can access the most appropriate treatment.  Which brings us to…

TAKEAWAY #2GETTING EXPERT HELP IS THE FIRST OPTION – NOT A “LAST RESORT”

This bariatric surgeon’s office got it right. While it may seem to make more sense bringing in an outside advocacy firm like ours is done as a last resort after the appeals are exhausted and unsuccessful, the fact is waiting that long makes it much less likely we can help. As the patient’s first advocacy option, we get the advantage of coming in right at the beginning, setting up the strongest case.  Earlier involvement means maximizing the number of bites at the apple – most plans have multiple levels of appeals to battle. Getting an expert advocate involved as early as possible after the denial is a “best practice” if getting the “no” to become a “YES” is the goal. Knowing the fight doesn’t end even when they issue a so-called “final” denial is incredibly important to know.  Insurers don’t get to end things on their terms exclusively.  People needing bariatric surgery can and should fight, even after the insurance company says its final “no.”  Which leads us to…

TAKEAWAY #3:  NEVER UNDERESTIMATE THE CRITICAL ROLE PLAYED BY THE INDEPENDENT REVIEW PROCESS (IRO)

One of the reasons patients and providers should be optimistic fighting denials is because in the vast majority of circumstances the final decision-maker is going to be somebody completely separate from the insurance company. This fight entails making sure the IRO request is reviewed by someone who knows the territory from both a medical point of view (such as an experienced bariatric surgeon), but also someone who knows that they are not bound by the insurer’s medical criteria! Rather, they should use appropriate national and international standards along with their own training and experience as guides for the decision.

This third takeaway bears greater emphasis: the independent, external review process is never bound by the insurer’s medical criteria which is why it is critical to submit medically-appropriate cases for authorization and why it is critical to appeal any denial based on inappropriate criteria.

We are mindful of the discrepancies between payer medical policy and the guidelines or care standards set by specialty medical societies like the American Society For Metabolic and Bariatric Surgery (ASMBS). Those recognized standards are what should be used by insurers, but that hardly ever happens.  This means patients needing surgery have the option of walking away from a denial or tenaciously fighting it.  We know the fight must happen, even when it is nearly certain the insurer will refuse to change its mind.  Knowing we are setting up the appeal to ultimately get a decision from an independent, external physician reviewer governs how the case is handled right at the beginning, starting with the surgeon’s office “who gets it right.”

So whether you are the patient or their caring provider, keeping these three critical takeaways at the forefront maximizes the chances a person needing bariatric surgery will get it.

Patients Win – Payers Lose – Life Is Good!

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