CIGNA battle - We finally won-here's our story

[Guest guest]

Okay now that the kids are in bed I can sit down and tell all of you

fighting that rotten CIGNA insurance co. what we did to get approval.

Hope it helps but I doubt it.

We waited a month for preapproval and got a big no, its cosmetic.

We had our prescribing physician call the med.dir. Ahmed that denied

us and he just insisted it was cosmetic and told her to tell us to

appeal. He made her so mad she was still fuming when I saw her six

weeks later.

We next wrote CIGNA at PACES and asked for further explanation,

stating we knew for fact other babies were covered. We asked for

definitions of medical necessity and cosmetic that they used, the

SPECIFIC criteria our case was judged on, copies of all documents

used in the decision process and any further information needed to

make the claim acceptable and the reason why. We cited a specific

page in our SPD book which said we were entitled to this information.

The reply from CIGNA-this letter is being considered your first level

appeal. Get us any further information in 10 business days.

We used the CIGNA letters in this database as guide and wrote a four

page letter and appeal packet. We pointed out our doctor's letter,

the AMA guidelines, the congenital nature of our daughter's problem,

and the fact that we'd asked for further explanation as we knew other

babies were covered and got no reply. We included pictures from CT,

obstetrical records substantiating " in utero constraint " , a news

article from the Sun Sentinal about a plagio case in Miami in 1998

which was paid after a first appeal, and a lot of the peer reviewed

journal articles that were referred to in other people's letters on

this site.

I also pointed out that CIGNA had given preapproval for us to see a

medical specialist to treat plagio since she was two months old and

had given it until June 2001, and thus by doing this they had already

acknowledged the medical necessity of treating plagio and per their

own policy did not pay for specialists that were not medically

unnecessary. We hammered that our specialist was in in-network

provider and director of the children's rehab program at her hospital.

So we sent this book and the denial letter for first level that came

back said " The Technology Evaluation Center, an independent and

nationally recognized organization, studied cranial orthosis for

plagio without synostosis extensively and decided it didn't meet

their criteria. Further digging found that the TEC is just a dept.

at BCBS and CIGNA bought this crap for $1500 to use in denying

bands. Tim Littlefield heard in the fall of 1999 that BCBS was

putting together a panel of " experts " to review cranial orthosis and

tried to get on it with no luck. BCBS hand picked the panel and

their " extensive " assessment was issued Feb. 2000. The assessment

has not been peer reviewed. I asked to see it and was denied cause

its copyrighted. I about flipped when I called BCBS to buy a copy

and they told me $1500 (but the executive summary is free). The nice

lady gave me a lecture too for free about how the natural etiology is

that the babies head will get better on its own. Anyone want her

number?!

We could see at this point that things were looking " crooked " so we

gave an identical copy of our appeal packet plus the gibberish above

to UPS. They reviewed it here, faxed it to corporate on Tue. and by

this morning calls had been made and CIGNA agreed to pay us. I just

assume 100% but we haven't received the letter yet. I will accept no

less.

I let my appeals coordinator know about all this stuff and I kept her

on my side. I needed a friend not an enemy. I cooperated with her

when she needed stuff by a certain date and was just my regular

friendly self with her. She was nice to me and I think genuinely

tried to help. I tried not to call her unless it was necessary and

faxed letters asking my endless questions and gave her reasonable

time to work on the inquiries. Most of the time these are just

people working a job for a dime like us and they are sick to death of

super frustrated folks like us taking it out on them. Give them a

breathe of fresh air and a joke and you might get an ally.

I honestly did find a reporter at the Miami Herald who is doing a

story about what people go through when they take on their employer

in a couple weeks, and I hope this plagio case is highlighted in

detail. Then when its published all of you can get a copy online and

send it to your appeals coordinator in your packets. AND SAY SEE

THIS!! I didn't bluff or make idle threats to my appeals

coordinator. If I was talking to a reporter I gave her a name and

phone number and email. I let her know I was all business.

This has been such a learning experience. I found using the phone a

waste of time and just increased my blood pressure. Certified

letters and faxes worked better cause the paper trail was better for

the dept.of insurance complaint, which I still plan to file cause

this stuff with the TEC and not answering questions and putting

everybody through this process only to give in over and over again

seems " crooked " . An attorney might say " bad faith " .

Try writing the CEO of CIGNA directly. That was on my list, and who

knows, we haven't actually seen cash yet.

Email me if you have further questions and please forgive the

wordiness. My thoughts are rambling.