Every day is exciting when we get a payer’s denial overturned. Win or lose, each case presents its own challenges and important lessons learned.
Today we found out we were successful with another Cigna bariatric surgery appeal. Whether you’re reading this as a patient who is researching does Cigna cover weight loss surgery, someone who loves that patient, or the provider committed to caring for the patient, there are at least three important lessons we can take away from this experience.
A Lap Band Conversion Denial
This patient’s situation 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 and she began having problems, most notably suffering from severe GERD that 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 many patients. Just as common was 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.
The reasons Cigna gave to support their claim that the procedure was not a “medical necessity” were:
- A “technical failure” of the band, as defined by Cigna, was not established to their satisfaction;
- Without a technical failure, the patient did not meet Cigna’s criteria for reoperative bariatric surgery; and lastly,
- There was no evidence the patient was compliant with her postoperative diet and exercise regimen.
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, so we got to work. Twice Cigna denied the internal appeals we filed, which wasn’t entirely unexpected. We were actually using these appeals to position 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.
Our plan worked, and we won the appeal for the patient. Let’s look at three takeaways arising from this patient’s success:
Takeaway #1: You are not stuck with either the payer’s decision or their medical criteria!
When it comes to bariatric surgery, insurance company medical policies are often out of step with established clinical standards. If you have been denied coverage for bariatric surgery because your case does not meet an insurance company’s criteria, don’t just accept their assessment!
In this case, the surgeon’s office made the preauthorization request for bariatric surgery despite knowing the patient did not meet Cigna’s weight loss surgery requirements and conversions. Too many bariatric programs don’t take a chance on patients who do not meet a plan’s official medical policy. It’s always best to focus on pursuing the most appropriate treatment plan, regardless of payer medical policy limitations, by submitting an excellent preauthorization request. 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 #2: Getting expert help should be your first step, not a “last resort.”
This bariatric surgeon’s office got it right. While it may seem to make more sense to bring in an outside advocacy firm like ours as a last resort after appeals have been unsuccessful, the fact is that waiting until the appeal process is exhausted makes it much less likely we can help. It’s important to get an expert advocate involved as early as possible after the denial, so we can set up a strong case and have access to multiple levels of appeals. Even after an insurance company issues a so-called “final” denial, the process doesn’t necessarily end. 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 when fighting denials is because in most cases, the final decision-maker is going to be somebody outside the insurance company. It’s important to make 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. Instead, they should use appropriate national and international standards along with their own training and experience as guides for the decision.
To emphasize: 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 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. 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.
So whether you are the patient or their caring provider, keeping these three critical takeaways in mind will greatly improve a patient’s chances of getting the bariatric surgery they need in order to live a long, healthy life.
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If you have been denied insurance coverage for a necessary medical treatment or procedure, PRIA Appeals can help!