ThinnerTimes - Gastric Bypass and Lap Band® Forum - View Single Post

Baron Patrick · 12-05-2006, 02:47 PM

Whitney - I called them and their representative said it was okay. I added this in my letter. Thank you.

Zen - You don't sound discouraging, I appreciate your comments! I took out all the "emotional" parts, and tried to use a bit stronger language.

Here is the full, revised letter:

Cigna HealthCare December 5, 2006
National Appeals Unit
P.O. Box 5225 Scranton, PA 18505-5225

This is in response to the letter your letter dated November 14, 2006 denying approval for Gastric Bypass surgery.

Member Name: Patrick S Burke
DOB: 12/26/1957
Member ID#: U05469010-01
Health Plan Name: CIGNA HealthCare of California, Inc.
Requested Provider: Inland Valley Medical Center
Requested Service: 43644 Laparoscopic Roux-En-Y Gastric Bypass
Requesting Provider/Physician: Dr. David Suh
Authorization Request Reference#: BTL26TK1

As stated in the denial letter by Ajani Nimmagadda, MD - “based on the information provided by the requesting provider/physician, you do not meet the established medical necessity criteria or guidelines for laparoscopic roux-en-y gastric bypass at this time.”

“Per CIGNA Clinical Guidelines, coverage is provided for bariatric surgery when all of the following criteria have been unequivocally met:”

“A body mass index consistently 40 or greater for a period of at least one year or a BMI of 35 or greater with evidence of significant other ailments (co-morbidities) such as uncontrolled hypertension, uncontrolled diabetes, or severe heart disease that are associated with obesity (comorbidities) that have defied conventional on-surgical treatment.”

I have been obese literally all my life, with a BMI consistently between 45 and 50. My current BMI is 45.5. I’m confident you are acutely aware how obesity significantly diminishes one’s quality of life, health, finances, and a reduced life span.

Based on your criteria, I am not required to prove co-morbidities as my BMI is over 40. However, in order to help you to make an informed decision, I must remind you I have been diagnosed and being treated for Type II diabetes for nearly 1 year. I also have a lower back injury; the pain being exacerbated by my weight, including joint pain in my knees and ankles. These have all been documented by my doctor.

Your second criteria states:

“A thorough evaluation by a multidisciplinary team for suitability and appropriateness for surgery that includes a separate medical, surgical, nutritional and mental health evaluations.”

I have fulfilled all your criteria, and all documentation has been submitted to your office twice. Your office also sent an acknowledgement stating you have received the required documentation. If necessary, my doctor will be more than happy to resubmit this information, again.

Finally, your third criteria states:

“Documentation of a minimum of regular, active participation in at least one recent 6-month weight loss program within the past year that is directed by a physician who does not perform weight loss surgery. Diet programs/plans such as Weight Watchers, Jenny Craig or similar plans alone would not be considered a physician-directed weight loss program. Similarly, physician-directed programs that only include pharmacological (medication) management would not be considered a physician-directed program. The submitted material must include clear evidence of at least 6 consecutive monthly visits devoted chiefly if not entirely to weight management and documentation at each of these visits of the following:

• Current weight and vital signs;
• Progress made since the last weight management visit;
• Current dietary intake;
• Current exercise program or list physical activities performed;
• Discussion of behavioral interventions used to reinforce the weight management program.”

I have been obese since my early teen years. Having experienced various diets, and exercise programs throughout my life have proven to be ineffective in the long term.

My doctor instructed me to join Weight Watchers, as she was certain this will satisfy your requirements. I also called Cigna and asked specifically if Weight Watchers is acceptable, and was told yes by your insurance representative. I have been diligent in ensuring I completed this six-month monitoring, along with periodic follow-up with my doctor. This documentation has also been submitted for your review.

I have researched bariatric surgery for over a year and a half, and discussed this at length with my family, my doctor, and surgeon. I believe my case of medical necessity has more than been established based on your guidelines. I respectfully request you to please review, and reconsider your decision.