Question:
CAN ANYONE HELP ME UNDERSTAND MY POLICY WITH UHC PPO ?
MY POLICY STATES THAT THEY DO NOT COVER WEIGHT LOSS PROGRAMS WHETHER OR NOT THEY ARE UNDER MEDICAL SUPERVISION. WEIGHT LOSS PROGRAMS FOR MEDICAL REASONS ARE ALSO EXCLUDED. DO YOU THINK I HAVE A CHANCE AT SURGERY? — PATRICE T. (posted on August 10, 2003)
August 10, 2003
Tough call. It all depends on what they consider a program. Personally I
do not consider surgery a program. I think they may be referring to the
weight watcheers, optifast etc. I'd go for it. Call them and ask about
the process to get approval for WLS due to morbid obesity and other medical
conditions and see what they say. If they say it is not covered ask them
to point you to where in your policy it clearly says this. If they direct
you to this statement then tell them this is not a program, it is surgery
that permanently alters your body. Don;t give up without a fight. I think
this one is vague enough that you might even be able to win it in appeal if
it came to that.
— zoedogcbr
August 10, 2003
I would definatly call them, I have UHC EPO and the covered 100%, but if it
is through an employer it just depends on what they payed for......GOOD
LUCK!!!
— Saxbyd
August 10, 2003
I'm having the same problem right now. I was denied about 1 1/2 weeks ago
and just sent my appeal letter. My denial was based on a general exclusion
in my policy which states, "Health Services and associated expenses
for the surgical treatment and non-surgical medical treatment of obesity
are excluded." However, every time I speak with them on the phone
they tell me that wls is covered for morbid obesity. I definitely meet
that criteria with a BMI of 45.9 and many co-morbidities. Since the
wording in your policy does not specifically exclude wls for morbid
obesity, I think you may have a chance. Go for it, and don't give up!
— angie305
August 10, 2003
stop sorrying. a "program" is like you going to Weight Watchers
or a gym and asking them to pay. If your Dr. advises this, it will be for
medical necessity. I have the PPO and my friend has EPO. Neither one of
us were asked for anything extra or to jump through any hoops. Unless your
employer has placed "weight loss surgery" as one of THEIR
exclusions, you are fine (if you meet the BMI criteria). We work for
American Express. Call the number on the card and ask this exact question:
"Do you have weight loss surgery listed as an exclusion? good luck
— Donya P.
August 10, 2003
Unfortunately I had the same exclusion as Andrea below and was denied twice
for this surgery (BMI of 55). They said they absolutely would not cover
this surgery and even contacted Walter Lindstrom and he let me know that he
had never won a case against UHC. Sorry for the bad news but that was my
experience. Seems like some people though can get through and around
that?!?! Good Luck to you!
— SMG I.
August 11, 2003
That is not thier standard exclusion for WLS. I would try it. UHC is very
specific with the WLS exclusion.
— RebeccaP
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