Round 2- CIGNA 2, Lori 0

I was shocked to pick up the phone today to hear Jennifer's (the insurance coordinator at My New Self Bariatric) voice.  She was cheerful.  I was hoping this meant she had good news for me.  She told me she got a call from the medical director at CIGNA.  Then she dropped the bomb that once again he chose to deny my request for gastric bypass surgery on the grounds that I haven't been "fully compliant" with the medically supervised program.  His concern was that I'd had my band drained in 2010 and that it's been dormant for 3 years before I requested the surgery.

Um........it took me through 2010 to gain all my weight back (and then some) to have the desire to try again.  Then by 2011 I'd lost my job and spent all of 2012 uninsured.  So forgive me Mister Medical Director for not moving according to your plan or expectation!  <yes I'm pissed>

Trying to hold back tears, my first question to Jennifer was, "What now???"

She suggested I revisit the lap band with Dr. Scott, get adjustments and let him monitor my results and go from there.  The thought of puking up every bite I take is so unappealing to me right now I can't even see straight.  BUT I have to "play the game" in order for them to see that it didn't work for me.  Apparently the slew of clinical pages from Dr. Malley's office in Kansas (3 yrs of history) wasn't enough.

Obviously I'm the only one who is going to be beat into submission here.  I made an appointment for Friday, September 13th to have my first lap band adjustment since January 2010.  This should be fun!  I'm hoping we only have to try this for 3 months before we can resubmit for surgery.

I could be completely surprised and discover that with a totally different doctor, perhaps I can find success with the band.  That would be the ideal outcome.  Then I could lose weight and avoid the surgery altogether.  Otherwise, I have no idea how long or how hard I'll have to fight to gain approval.

Until then, it's being more mindful of the quality and quantities of the food choices I make and giving the band one last try.

I'll continue to blog throughout that journey, as well.....documenting the foods and success/failures I have along the way.

For now I can go back to making plans as the surgery doesn't look to be happening in the next few months!  So I'll continue to book accessible seating so I can enjoy a sporting event.  I'll continue to get the extra seat on the airplane when I travel.  I'll continue using seat belt extenders in the car and on planes.

And I'll start trying to move the mountain (150-200 lb weight loss goal) one stone (pound) at a time until I can get an assist.

If I can ever get surgery approved, I'd like to have it by year end. since I've met my deductible for 2013 and for a few other reasons, too.

I feel like the little engine that could.  I think I can..........I think I can....................

Nothing worthwhile was ever easy!

As you may recall, my case was presented to CIGNA by my surgeon's office on August 7th for approval.  CIGNA had 30 days from the 7th of August to make a determination.  Once approval for surgery is obtained, it can take up to 2 weeks to get "in" for the gastric bypass procedure.

That said, I've been very hesitant to commit to much in September.  I was SURE I'd gain approval and go under the knife by the first or second week of the month.

NOT SO MUCH.  Today I got a call from My New Self saying that the paperwork came back from CIGNA and it was a denial!  For some reason that option never really occurred to me.  Needless to say, I'm quite devastated and on the verge of tears as I write.

Jennifer (my insurance coordinator) at MNS did tell me that she thought they were wrong and why.  So she submitted it back to CIGNA for re-review.  Apparently they ruled it an out of compliance issue, as if I had not been compliant with the band.  But she went back and explained and showed them the documentation where the band had failed me, where my body had rejected it by vomiting for 3 years.  They also said they needed a referral from my primary care doctor.  I don't get all this insurance crap, nor do I want to.  But she went on to explain that they are a "Center of Excellence" and do not need that and also some other things she disputed with them.  So we'll see.

For now, all I know is I still don't know whether or not I'll get to have the surgery or when........so I continue to be non committal.  That's not good,  First, my boss wants me to start traveling more.  So I can't just books stuff then have to cancel all those trips.  Secondly, I really wanted to volunteer for some of the benefits that are being hosted for a friend.  They are all coming up the first week or so in September.

What Jennifer did explain is that this isn't the end of the road.  The "war" is not over.  We just lost the first battle.  Next step is to wait for CIGNA's "re-review" determination.  Then IF they deny it all over again, she will have the surgeon do a "peer to peer" with the medical director at CIGNA.  I'm praying she can beat them into submission!!!

Right now I feel like I've been sucker punched; and I'm bummed.  I'm so worn and ragged from all the other battles I deal with on the daily (trying to fight with the bank and short sell my KS home, dealing with complete and utter chaos in the work environment, trying to get a child in to see an Autism specialist, etc) that I don't know how much fight is left in the dog!

Fortunately, for me, I don't have to do head to head battle, Jennifer is representing me.  My job is to kick back and wait.

That's just it.  For a control freak like me, the waiting is always the hardest part.

I'm afraid to ask for your prayers given all those I've requested lately for my aunt and my friend.  So how 'bout sending some good "juje" instead?

I'll keep you posted when I hear more...............Have a great week.

Lori