Journal

Journal

5/21/03 Received my denial letter from Intracorp who provides reviews and case management for Cigna HealthCare.
Determination: Non-certify Laparoscopic Roux-en-y Gastric Bypass Rationale: Bariatric surgery is a covered expense that is dependent on medical necessity. Lacks documented history and documentation submitted as evidence of active participation and reasonable compliance with at least 2 professionally supervised weight loss programs for a minimum 26 weeks in each program, one completed within the preceding 12 months. Programs should include weigh-ins on a regular schedule, at least monthly. Additionally, there is no documentation of one or more clinically significant co-morbidities which have failed to respond adequately to non-surgical treatment methods including appropriate and adequate medication.
We have determined that the requested services do not meet the definition of medical necessity found in your benefit plan.
Intracorp guidelines for bariatric surgery are higher than Cigna's guidelines, looks like left hand does not know what the right is doing. In this letter there is an opportunity for a Doctor to Doctor review of my case, hopefully Dr. Atkinson will convince them in changing there decision on this procedure. This is a definite delay tactic with Intracorp and not sure how Cigna stands or if they ever change any decisions by Intracorp, lets hope for the best.
Please Lord help them, for they are blind
Better yet put them in my body for a period of time..

6/2/03 Well a week in a half has gone by with little progress with the insurance company or anyone for that matter. We still have a lot of finger pointing going on from all parties. Cigna has sent me the appeals paperwork, I also requested that they provide in writing the guidelines for Bariatric surgery. On Saturday I received a copy of the guidelines, but they came from Intracorp instead of Cigna. Over the past several months Cigna was tell members the guidelines for Bariatric surgery were; 3 diets in your lifetime with one within the past year a minimum of 12 weeks and a letter from your Doctor. Now it appears that this is not the case with Intracorp who does Cigna’s case reviews and having a higher standards; one must be medically necessary, BMI over 40 for at least a year, 2 professionally supervised weight loss programs for a minimum of 26 weeks each and medical documents supporting both patients diets and co-morbidities issues. As of last Friday Dr. Fisher’s office and Intracorp have not talked yet about my case, that’s two weeks of no progress and very frustrating. So it appears that my surgery date of June 11th is gone. Last Friday I sent an email to Obesity Law & Advocacy Center for advise on my case, they returned an email with an attachment – Agreement for Professional Services, which I will review and most likely retain there services in the near future. I was advised to contact my benefits department in regards to my case to see what they could assist me in any manner. Friday was not a good day for me; I went to Dr. Fisher office with very frustrated attitude with their lack of support and not returning my calls. I latter sent an email to Dr. Fisher and his Staff to apologies for my action. We will see how this week goes and if any progress is made.

6/13/03 Its been a little since my last entry, well I have my HR department (Benefits Group) working on my problems with Cigna. Dana has been very helpful in the matter and finally gave me additional information and direction in this case. I have put together an appeal letter and more documents from doctors, additional diet history and organized everything into a binder. I am still waiting on additional doctor records to complete this package and hoping to send this to the benefits department next week. It appears to me that everyone is still not understanding the main issue I have with Cigna and there double criteria that I have faced over the past several months. Currently my paperwork shows over 52 weeks of diet history, it appears they are splitting hairs over the new criteria of 2 supervised diets at 26 weeks long one within the past year, from the start of my journey was under the criteria of 3 diets within a lifetime one supervised being within the past year at least 12 weeks. However I believe I have everything together that they may be requiring for this appeal, I also have made a copy in case I need to have the Obesity Law Center take over my case. I also have been given a point of contact for the Governor’s office and the Insurance Commission for Nevada to assist in my case if needed. It has been quite a journey so far, I would like to say thank you to all for the support that I have received from family, friends, co-workers and other WLS friends. Just remember should anything happen to me during all of these delay tactics by the insurance company (Cigna/Intracorp), I request that my family take very strong legal action with all parties involved with neglect in my pursuit of Weight Loss Surgery. Enough on that note, I do not plan on going anywhere soon. The Surgical Weight Control Center has put up 2 billboards in town with Sue's picture on it, Both Sue and Vince have been my inspiration in this journey. I have taken a picture of the billboard and loaded it on my photo page.