Fully Funded Appeal?

Hi, I have a question that I hope someone can answer for me.  I have UHC Choice Plus with an exclusion for wls, it actually says "surgical or non-surgical treatment for obesity, including morbid obesity".  I am in the process of appealing their decision based on two points: first that both myself and my surgeons office had been told prior to any pre-surgical testing that wls was a covered benefit under my plan, second: that this surgery is medically necessary especially as I have been recently diagnosed with severe obstructive sleep apnea.  I know my chances for approval are slim to none, but felt I needed to follow procedure. My question is this: I have found out that my plan is fully funded and live and work in MO, is there any other option in appealing, for example: appealing to the State Insurance Commision?  I am willing to take this as far as I have to in order to get my insurance, that I pay so much for, to pay for this surgery.  Self-pay is just not an option for me as a single mom.  Thank you for your time.

I am sorry that you are experiencing issues with your health-insurance company.

As always, you have the right to appeal any decision by your insurance company. Based on the verbiage that you provided about your plan, clearly, bariatric surgery is not a covered benefit. It is unfortunate that both you and your provider's office received erroneous information about that particular benefit. From experience from working with UnitedHealthcare, it is not common that the company will administrative pay a claim or authorize a procedure that is explicitly denied in the explanation of coverage. I will simply coach the representative(s) who gave you the wrong information.

Your options for appealing would be 1) going through the appeals process with your insurance company, which you are doing, 2) filing the appeal with your state's Department of Insurance or Managed Health Care, and 3) talking with the benefits administrator of the employer. In most cases, both entities usually have a responsibility to respond to your inquiry and adjudicate it within 30 days of receipt. The time requirements will vary between states, so please check your respective state's Web site.

My best wishes go out to you while you muddle through this quagmire of red tape.