Question
What is the name of your state?What is the name of your state?ohio I have had a thrombosis which destroyed valve in leg and now my ankle is black and blue and other problems. Cigna isurance has denied my doctor's appeal twice for the venous closure procedure saying that it is excluded in my policy. I do met Cigna's critera of medically necessary for the procedure. I have filed complaint with the state of ohio. Is there anything else I can do to try to get coverage for this procedure.Thanks
Answer
It doesn't matter whether it is medically necessary or not; an insurance carrier is not required to pay for anything that is excluded by the policy unless there is a state law specifically requiring that they pay for that specific procedure.
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I'm having trouble with the poster's wording / description of the situation. The poster states that he / she is meeting the requirements of Cigna's medical necessity for the procedure, yet he / she is also saying the procedure is specifically excluded. So far, that is my understanding. But, I don't see how both situations are possible. A procedure may be excluded regardless of medical necessity--ie, no coverage. But, if Cigna lists criteria where the procedure may be covered as medically necessary, I wonder if the poster understands those criteria. I think Cigna will either exclude completely regardless of medical necessity or the procedure is allowable under the medically necessary circumstances. I cannot tell which is which because I am not familiar with the vein closure procedure the poster describes. But, with more info, perhaps. Also, there are likely other provisions of an insurance plan that apply. One can rarely read one page to come up with a determination. Is "investigational" or "experimental" a factor here?
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VNUS, maybe? Can you relate any conservative treatements that may / may not have been tried to date? lkc15507
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There are plenty of services that could be medically necessary, that does not mean that the insurance carrier must pay for them.
If this procedure by the OP is specifically excluded from coverage, then he or she needs to pay for it. I am sorry.... I understand it was medically necessary, but it's excluded from your policy as a payable benefit.
If you can, consider changing insurance carriers. But first, see if your condition would fall under ANY pre-existing condition policy.
Or, if the procedure has corrected your problem, and it's not something to worry about in the future, that would be a good thing.
Your physician should have - actually YOU should have - contacted Cigna prior to the procedure to ask if it would be paid for.