United Healthcare Will Kill Me Before My Weight Ever Will.

I am at a loss. I am trying to keep this as brief as possible, so forgive me if you get lost in the muck and the mire.

1. Decide in August to have LAP-BAND® done w/ Dr. Liu.

2. UHC rep says won't be authroized b/c Dr. Liu doesn't accept insurance.

3. Confirmed by rep 2.

4. Rep 4 says no way. Will be covered at 90% of what's eligible. Must turn in predetermination request.

5. Ask reps 4 & 5 and coordinate w/ Dr. Liu staff what is required (just paperwork from his office. Submitted.

6. Denied. Not a covered benefit.

7. What? That's not what reps 4 & 5 said!

8. Oops. You're right. Denied because no proof of morbid obesity for last 5 years.

9. Submit proof.

10. Denied for not submitting proof of morbid obesity. Argue with Reps 6 & 7 for 45 minutes on the definition of "proof." They say HEIGHT AND WEIGHT IS NOT PROOF. Must be a ICD-9 diagnosis from a chart. I said YOU CAN'T GET AN ICD-9 DIAGNOSIS OF MORBID OBESITY W/O THE HEIGHT AND WEIGHT!

11. Get transfered to medical review unit. She tells me I was denied because I failed to submit proof I participated in medically supervised weight loss programs and do not have high blood pressure, heart disease, Diabetes, or obstructive sleep apnea.

WHEN WAS ANYONE GOING TO TELL ME THE REQUIREMENTS OF MY OWN PLAN?

I've participated in countless weight loss programs (medically supervised ones, too), but the closest thing I have to any of the above is insulin resistance. I feel like I am getting the run around, and no matter how many hoops I jump through, they will find a reason to deny it.

Anyone get LAP-BAND® approved with a situation similar to mine?

Sorry to hear UHC is treating you so bad. I had a similar experience. I had a BMI below 40 and 2 different UHC reps told me over the phone that as long as I had 2 co-morbidities, I would be covered. I have more than 2 recognized co-morbidities. UHC covered all the pre-surgery procedures. After the doctor agreed to do the surgery, he submitted the pre-approval papers and I was denied. The first explination was that he was an out-of network doctor. Then it was that my BMI was too low. I finally got a look at the coverage documents and my company only authorizes surgery with a BMI of 40 or higher and done by an in-netowtk doc. I appealed, got doctors' letters, etc. but UHC denied. Now my only recourse is to sue my employer for having such an arbitrary requirement. Needless to say that will go over big with my boss. I ended up self paying. My surgey went fine and I am on my way to better health. I was lucky to have the ability to self pay. I hope you have a better outcome with UHC. Good luck.

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KingsFan

I'm going through something similar with UHC. I first checked with my corporate plan document to see what was covered. WLS is covered with pretty standard guidance--BMI 40+ for 5 years OR 35+ with any of the listed co-morbidities. I also needed evidence of a medically-supervised weight loss program. I fit the second category of BMI and had participated in a 6mo hospital program a couple of years ago. I thought insurance would be the LEAST of my problems....NOT!! They denied me on the first submission for not having a letter from my PCP with weight hx--and this was just a couple of days before I was to have surgery. My surgeon first talked to them, then we sumitted everything they asked for in an appeal. My appeal was denied, with them telling me that I didnt meet the 40+ BMI requirement. I have a corporate advocate involved now that is working with UHC to straighten this out and have also contacted the attorneys at obesitylaw.com. They came back saying I definitely have a case and that it looks like I can use Allergan's (the maker of the Lap-band®) appeals/advocacy program at no cost to me. I'm hoping that one of these actions finally settles everything. Your company should have a written plan booklet (paper or online) that you can reference for the exact requirements in your plan so you can see just what you need. Good luck!!! I know how frustrating this is.....we have to keep pushing back on these companies....

Thread Starter

Ugh! My UHC plan is a corporate plan, too. My husband works for a pharmaceutical company. MY BMI is over 40, but on top of telling me that doctors notes of height and weight are not enough (see new post in this section) they are telling me that I have to have the co-morbitities WITH a BMI of 40! I had them read to me the plan requirements (because God forbid I be allowed to see a copy of my own plan!) and it states clearly BMI 35+ morbitities. I am beside myself.

My corporate advocate told me last week she can no longer help me once it's gone to appeal. But I'm not buying it.

Thanks for the tips on obesitylaw.com and Allergan. I'll look into it.

I wish you luck!

p.s. My husband's company is on the east coast, so I wasn't able to call them in time today for a copy of my plan. Hopefully I can reach someone on Monday.

Hang in there, I felt the same way with United Healthcare. Let me tell you what I did and see if it will help.

I went to Dr. Felix Spiegel back in March/April (can't remember exactly) and went through the seminar, etc. Did all the paperwork for insurance and then united healthcare came back and said they needed the 5 year history, provided that in a letter from my dr. they said that was not proof enough and denied me because I was not sick enough. I appealed and was denied again. Now mind you, I have documented high blood pressure, severe sleep apnea, and depression. So I gave up. The problem is that Dr. Spiegel's office did not help me fight and that is why I gave up.

My best friend told me a friend she knows went to a different doctor that was a patient advocate which meant they would fight for you and help you get approved. I then went to Dr. Ferrari in August and and after a through discussion with his admin staff they told me the copies of the drs notes is what is needed. So I had to go through this long drama with Kelsey Seybold but I was blessed to find a guy that gave me what I needed. But I got discouraged because it was October and I had not heard anything, (hurricane Ike delayed stuff) I finally got a letter from the insurance on Thursday and was approved.

So I say this, make sure the dr you choose does the fighting for you (patient advocate is the word my dr uses) because in my case that made the difference.

Hope this helps.
Nina

I have UHC, they pre approved me on the first day paperwork was submitter. It paid everythng except the Surgeon, because he submitted out of network, I appealed but to no avail. so I feel lucky that it did pay the hospital portion, all labs and tests for pre-op.

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H298/S255/C175/G150-155
Fills 1/08/08~3cc*2/26/08~1.5cc /1/22/09~.6cc =5.1cc's
Banded 11/12/07 Dr.Naik~Bakersfield, Ca

Interesting m&nsmama.....I work for a large, east coast-based pharmaceutical company.....maybe we should talk more ....if it's the same one, I have a copy of the booklet I could send you. Also, I learned from our corporate advocate that the surgeon's office has to make all the contacts in order for the company person to get involved. If I had submitted the appeal than they could not help me.

I agree with the other posts about having an advocate in the surgeon's office. The group I'm working with are just great.....they are working tirelessly to help me get this resolved, calling UHC and collecting medical records as needed. I find it interesting that with UHC it seems the "requirements" are as varied as the different people at UHC who provide the information! For my appeal, they specifically told my surgeon during their "peer-to-peer" conference that I needed a letter from my PCP with my weight history and co-morbidities, not medical record copies. That is what we supplied (and to ensure the content was right, I wrote a sample letter for the PCP so they would see what was needed. They ended up using that letter verbatim). I think it's important to keep pushing as many ways as we can. I'm so irritated by all this......I SHOULD have been one month post-band by now!! My surgery date was September 9th.....

I have UHC (through the railroad) and was approved within 24 hours of submitting paperwork, but let me tell you, I took every precaution when submitting my paperwork so I couldn't be denied. My BMI only got to 37, but I was documented as being in the lower to mid 30's for the last 5 years. I had mild sleep apnea, depression, frequent migraines, back pain, knee surgery... I sent in copies of my weight watchers weigh in cards for the year - and then some - when I was on it too. I think that helped a lot. I did the current surgeons diet and weighed in with him too - which I lost - but I could show proof that I had tried and tried and paid out of my own pocket to get weight off and nothing was working.

I also opened a carecredit account just in case my insurance doesn't cover something immediately... but under my benefit, the doctor and hospital are in network so I pay nothing... just my inital visit with the surgeon of 35.00. On the other hand, I had to pay for my nutritionist, and all the co-pays to psychologists, psychaiatrists, general practitioner, and the 'scrpits over the years. Carecredit does offer bariatric surgery financing and their rates are much lower than anything I have ever heard of before! I know my doctor and hospital both take them and it might be a route you can go and fight the insurance later?

All in all though, I do feel lucky that my coverage is so good and wish it were just as good for everyone else. Just keep fighting, it will be worth it...

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Uhc is one of the worst to get anything done. Fight it!

Dont worry keep on going ! I just got approved from UHC they submitted in sept 20 and i got approved oct 10 but they doctor put me on managed weight in june :)

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SURGERY DONE BY DR DAHIYA LAKEWOOD,CA




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I am working on an appeal with UHC. Does anyone have a sample of a letter from the PCP diagnosising morbid over a minimum of five years? I need to send something to my doctor showing him sort of what I need it to say..