UHC Self Funded Plan and 2nd Level Appeal

I was initially approved for the RNY, but want the VSG, my plan covers all "accepted" forms of variatric surgery, lucky me!. UHC denied because it deems the VSG “experimental and unproven”. Research has convinced me that this surgery is the best for me having the least (almost none) complications and almost the same results as the RNY.

I submitted the first Appeal to UHC with documentation and studies and also DENIED. I’m now in the process of the Second Level appeal which has to go to my Employer, not a fun prospect. I’m waiting for a letter of support from my surgeon to submit to my HR department next Wednesday. I wrote a second letter of appeal asking for approval and I’m looking for suggestions and tips in the hopes of a reversal.

My HR department has already told me that they usually follow the insurance’s directions but to go ahead and submit the appeal for committee review and “they will see”, not too encouraging, but that is where I am right now. Any help or suggestions you out there can send my way would be really appreciated. Keep your finger crossed and say a prayer for me or I’ll have to self pay.

A few things. 1) Is DS covered. If so, see if you can ask for a two -stage procedure, get the first stage which is VSG and then skip the second step. 2) Remind your employer that statistics show less complications with VSG than RNY (See Obesity help's VSG description which states the statistics for mortality, etc. and that you can be back to work more quickly. 3) My approval came because my surgeon didn't write Vertical Sleeve Gastrectomy -- he just stated gastrectomy. That procedure (same thing basically) has been around for 20 years as a treatment for stomach cancer (cut the cancer out and then close). 4) Go the the VSG board and poll how many folks got insurance approvals and what there insurance plan was. I was on CIGNA PPO and was paid everything but a $500 deductible on the hospital and co-pays for the PCP visits during the 6-month diet.