Question:
How do I check cigna medical requirements?

I have Cigna HMO and when I all and ask for specific criteria for things such as bariatric surger, breast reduction, etc. they just say the medical group knows it and wont give me the info. Does anyone know a web page to access this info from cigna???    — Keniki B. (posted on August 29, 2002)

August 29, 2002
I have been fighting Cigna for almost 5 months. They WILL NOT give you any answers over the phone. The standard reply is "ask your doctor". Sorry this did not answer your question but I just wanted you to know that you are not in this boat alone. Good luck!!!
   — Siddy I.

August 30, 2002
When I got my first denial from Cigna, if I remember correctly these were their requirements (Virginia): 1. At least 100 pounds overweight with a BMI greater than 40. 2. At least 3 physician supervised diets of at least 12 weeks in length, one must be in the past 12 months. 3. Multiple co-morbidities. 4. Statement of medical necessity from a physician. 5. Evidence that this affects your quality of life (can be physician statement). 6. Diet history It varies from policy to policy. Check with the policy via the hr dept.
   — Cathy S.

September 12, 2002
you're in luck b/c I just called Cigna today and asked for the EXACT requirements for weight loss surgery. Here's what they e-mailed me. Hope it helps you! "vexxtra" Dear Ms. @@@###: Thank you for your inquiry about the medical necessity criteria for gastric bypass surgery. Here are some facts about how the condition is evaluated: The Body Mass Index (BMI) is an objective measurement, which is currently considered the most accurate measurement of excess adipose (fat) tissue. The National Institute of Health defines obesity as a BMI of greater than 27.5kg, and severe or morbid obesity as greater than 40kg. A comorbid condition occurs when another part of the body becomes diseased as a result of the morbid obesity. Examples include: hypertension, gastric reflux, diabetes mellitus, coronary artery disease, pulmonary dysfunction, severe sleep apnea, lower extremity venous and lymphatic obstruction, obesity related pulmonary hypertension, symptomatic osteoarthritis of the knee, hip, or back. Gastric bypass surgery is considered medically necessary and will be covered under the terms of your benefit plan if all of these criteria are met: BMI Greater than 40kg for at least five years, or Between 35-40kg with additional documentation of one or more clinically significant comorbidities that have failed to respond to non-surgical treatment, including appropriate and adequate medication. Previous Weight Loss Attempts In addition to the minimum weight requirements, you must submit documentation supporting previous weight loss attempts. The patient must have actively participated and reasonably complied in at least three professionally supervised weight loss programs for a minimum of twelve weeks in each program. At least one of these programs should have included weigh-ins on a regular basis. Age and Risk The patient must be an acceptable age and risk for surgery. This is determined by the Primary Care Physician (PCP). Comorbidities The medical records should indicate that the PCP has made efforts to treat any comorbidities using standard conservative protocols. It's important you know that the referring physician must receive pre-authorization through CIGNA's Health Services Department by submitting clinical information supporting all of the above medical necessity criteria. Please contact your PCP to discuss possible treatment plans. If the PCP feels that surgery may be necessary and that you meet the above criteria, he or she can contact the Health Services Department to start the pre-authorization process. In addition, please know CIGNA HealthCare does not guarantee or represent that any particular benefits will be paid. Payment is based on the terms of the group plan and the patient must be eligible when receiving treatment. Ms. @@##$@#, I hope this information is helpful to you. Thank you for visiting our web site. Sincerely, A. Garcia Internet Customer Service Team CIGNA HealthCare www.cigna.com Please do not respond to this e-mail ------------------------------------------------------------------------------ CONFIDENTIALITY NOTICE: If you have received this e-mail in error, please immediately notify the sender by e-mail at the address shown. This e-mail transmission may contain confidential information. This information is intended only for the use of the individual(s) or entity to whom it is intended even if addressed incorrectly. Please delete it from your files if you are not the intended recipient. Thank you for your compliance. Copyright (c) 2002 CIGNA
   — AMY P.

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