Battling with the Insurance Co - CIGNA PPO

[Guest guest]

I called my insurer today to confrim they recieved my faxed Letter of

Medical Necessity that was sent to them last week from my DRS office.

CIGNA PPO of course has no record of a fax being sent last week. (The

Drs office called me last week to let me know once they had faxed it

out).

Since I had to have the DRS office resend I wanted to make sure the

LOMN included the necessary details so I asked again for CIGNA to

tell me what the critera Was as I got mixed messages the last time I

asked via phone call and query to their internet site. The criteria

on the internet site was much harder than what was read to me over

the phone on a previous query.

They told me there was no criteria. I said I knew there was because

Cigna told me what it was the last time I called as they looked it up

and read if off the screen to me.

They of course had no record of me calling. I responded with " then

how did I know the fax number as its not on your ID card, how did I

know to request a PREDETERMINATION with LOMN if you didnt tell me?

They supposedly looked it up and asked a supervisor who said there

was no criteria.

Cigna didnt give me the criteria until I pressed yet agian and then

quoted this to them:

California Health & Safety Code section 1363.5 mandates access to

these criteria including identification of the authors of the

criteria, the clinical principles utilized to develop the criteria,

the last time it was reviewed and updated, etc

This time they miraculously found the criteria, and they were more

certain of telling me all as I was upset. Ok so this time (third

different version) they told me the pre determination request for

gastric bypass needed to include the Letter of Medical Necessity

(LOMN) whose criteria included:

History

Physical

Height

Weight

Frame Size

Recent Labs

Blood Pressure

Medicines

Treatment Plan

Prognosis

Note... no mention of detailed diet history containing 3 medically

supervised weight loss programs in the last five years as the info

from a query to the generic Cinga site said.(ie for PPO, HMO?)

Cigna PPO FAX :

you need to get a person's name and desk number to fax " ATTENTION "

Some insurers refuse to provide access to the criteria for medical

necessity, even when denials are based on failures to

meet " criteria. " Ask how anyone can successfully challenge such a

denial without access to the criteria and background information upon

which it is based.

Lesson learned..

Ask for the name and desk number/extentsion number of the person you

talk to and document it with the date you phoned and the info given

and recieved.

Dont assume they recieve a fax... make them look in your record!

mary bmi 68

corona,ca

awaiting insurance approval

Dr Rabkin, San Francisco