United Healthcare Insurance
I am new to this site and am hoping to be approved by UHC for WLS. Many of you already have experience with them so I wanted to know if any of you have similarities to my story and what the outcome with the insurance provider was.
I have been overweight most of my life but never at the morbidly obese level until recently.
My insurance (UHC Choice Plus) approval requirements are that I have a BMI of 40 or above (I am 42) or 35-39 with 1 or more co-morbid conditions.
They require me to provide a 5 year weight history and a list of all the non-surgical weight loss methods I have attempted in the past (I've tried them all).
My only fear is that I haven't been morbidly obese (over 40) for 5 years. I have been off and on between the 35 to 39 range without co-morbidities. Basically, I have been overweight all of my life, but not always at the morbidly obese level. Can this hinder my chances of being approved?
I might be suffering from sleep apnea and am going through a sleep study on Saturday for testing. We'll see what that test determines. I'm sure this could only help my chances of approval. I am also going to a Rheumatologist because I might have some weight baring arthritis (arthritis runs in my family). By the way, do they ever take into consideration family medical history for surgery approval?
I had an appointment with a dietician today and she cleared me for the surgery. I just need for UHC to approve it, and I'll be ready.
Have any of you had a similar situation and if so, what was the outcome?
on 9/11/09 6:14 pm
So check you COC and then document everyone you talk to and get it all ie writing.
Also check your state laws to see what they say about wls surgery beign covered. Please feel free to read my blogs and post concerning my on going fight to what i need.
Zells_lori is 'abuddingrose'
I'm working on a letter requesting a waiver to the exclusion, but don't have a whole lot of confidence that they'll allow it. I, also, live iin Maryland, where we have a very fine WLS law... but the insurance policy was written in Virginia.
Lori, would love to see the text of your letter - the one that went to the AG!
My policy was written in California. As far as my letter to the AG I actually contacted them via phone and I was directed to do so by UHC.
Below is a chart of the states that mandate benefit coverage for surgical treatment of morbid obesity.
Over the week end I recieved two different letters from UHC. One was a list of phone calls that I had made to them inquiring about wls. and the other was directing me to contact the California Department of Insurance for Independent Medical review. Ironically I have been directed to the State Attorney General of Maryland, The Maryland Department of Insurance, and California Department of Insurance all by United Health Care.
Now talk about confusing. It is. How ever, i have forwarded all of the informaiton requested to the Attorney Generals Office Representative that Is handling my case. Compiled a package for the California Department of Insurance and One for the Maryland Department of Insurance.
So we will see what hoops they want me to jump through next. I am not going to go away.
I had gotten so frustraited on Saturday that I cried for about 3 hours. Also spent a small fortune yesterday to get copies made to send the packages off. Bottom line , like Zell said, They are playing burocracy games in hopes that I will just get frustraited and go away. and I need to just keep a steady pace, stay focused, and not get depressed about it because that is giving them what they want and making me ill at the same time.
Take each step as it comes and keep plugging along.
I honestly hope that this information has helped you
If you need any more information or just need to chat I am here.
Zells_lori is 'abuddingrose'
Could you please send me the link for that States chart? Our policy was written in VIRGINIA -I didn't think they had a WLS law - but according to that chart, they DO!!
Of course, NIH doesn't recognize VSG as yet, right? It's still "investigational"...
Sheri here is the link that you asked for. I hope it works for you. Make sure you read your policy. I have sent everything I have to several places. I think you have seen them posted already.
Good luck and keep me posted as to how things are going.
Hugs from Baltimore
Zells_lori is 'abuddingrose'
on 10/4/09 9:23 pm
My husband has UHC Choice Plus through his office. I was just lookng at your above list of states, we are in Georgia, and it appears that we were the first state to enact a law saying insurance coverage for WLS is mandatory. DH's company intentionally excludes WLS. Just so that I am understanding this correctly, this is against our state law, yes??? I have really craptastic credit due to a divorce several years ago and then losing my job this past winter, so I have no way to finance wls. This would be incredible news for me if I can fight it with my DH's company. They are a bunch of ultra-healthy people who do not think wls is ever necessary... I used to work there, I know. ;) THANK YOU for doing your research, this is incredible!
I had WLS (VSG) covered under UHC Choice Plus - but find out if your company is self insured. Basically means UHC is the front end administrator, but my company foots the bill for insurance claims. Mine is. I was rejected, then my appeal was rejected (I didn't have a >40 BMI for 5 years - it had gone down to ~38 for a couple of years). The second layer of appeal goes to my company - I got very lucky and the Bene manager said "close enough" on the BMI - I also got the VSG covered under insurance, which is rare I think?
I feel incredibly lucky for that outcome.
HW 366 (2004) * HW Pre-OP 271 (VSG) * CW 157 * GW 145
VSG - Dr. Paul Macik (Atlanta, GA) - 7/09
Post MWL Plastics with Dr. Peter Fisher (San Antonio, TX) 12/13
I definitely am keeping my hopes up. I really think that things will work out in my favor.
I have been looking into the VSG, but apparently my particular plan does not cover it. So, I am leaning towards getting the LapBand instead.
How is your VSG working out?
I am really trying to get this surgery done this year because the company I work for was sold this week and rumor has it that the insurance we will have next year will not be nearly as good as what we have now.
I need to take advantage of the fact that they do pay for bariatric surgery. Who knows if I can do it after this year. Well, I'm sure I can, but it's a lot more painful when the money has to come out of my pocket.
I have done all of my research and now just need to wait on the insurance to submit their approval.
on 2/13/13 6:11 pm
I was just told by UHC they wont cover my surgery because im not 21. My surgeon is doing everything he can to appeal that because he said it was a ridiculous claim and hes done patients as young as 16. Im tired of waiting. My friend had his when he was 20 why cant i? :(
I am sure you will get a letter, but I would ask them specifically for the documentation in your policy (or certificate of coverage) that excludes WLS coverage for those under 21. I see no mention of it in their online medical policy (Policy Number: 2012T0362P; Effective Date: December 1, 2012). It might be listed in your specific policy or cert of coverage, but usually those 18 and over are covered.
This might just be them grasping at straws to try to deny you on the first go around. I think your doc would likely be successful on his appeal - there are just too many studies showing the benefits of surgery, especially on the younger patients.
HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"
M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)