United Health Care Denial Question

Hey all,

I just found out today that UHC is denying me because back in 2007, while addicted to prescription pain meds, my BMI dropped to 39 and my only co-morbidity factor is high blood pressure. We have been working with Dr. Robert Davis in Houston and I spoke with his coordinator to see what the possibilities were of appealing. She said that the insurance copmany won't care what the reason was for losing the weight in 2007. All they care about is that my BMI dropped. Has anyone here had experience with UHC in this situation that could share what happened to them??

Thanks in advance!
Dan

Hey All, This is Dan's wife...let me add a few things to the picture...he has had the same two co-morbidities - high BP and high chloresterol all along. For our insurance plan - UHC Choice Plus - we have to show 5 years of obesity -  In 2007 he still had the same co-morbidities but his BMI dropped to 39.  I have an email from UHC stating:  "UHC covers a person with a min of BMI of 35 with complicating co-morbidities (such as sleep apnea or diabetes) directly related to, or exacerbated by obesity.

Does high BP and high chloresterol count as multiple co-morbidities?

Dr. Davis's office said they do not handle appeals for patients (kinda odd in my opinion when I see that other doctor's handle appeals for their potential patients)..

What are the odds that we can get this appealed? His current BMI is 43.

My UHC plan DOES count High BP and High Cholesterol as long as you are taking meds for these conditions.  My doctor is monitoring my high cholesterol for now, so UHC says they will not consider it a co-morb.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII /UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf /Tools%20and%20Resources/Policies%20and%20Protocols/Medical% 20Policies/Medical%20Policies/Bariatric_Surgery.pdf


Here is the medical policy for UHC. - It may depend if they consider high cholesteral a cardiovascular disease on par with the ones listed   They may not - I checked other health plans and High cholesteral is usually not listed as one of the qualifying comorbidities.  Things like Asthma and Arthritis are also not usually listed either.


Bariatric surgery is proven for the following:
1. Class III obese (BMI > 40 kg/m2)
2. Class II obese (BMI 35-39.9 kg/m2) in the presence of one or more of the following comorbidities:
Type 2 diabetes•
Cardiovascular disease (e.g., stroke, myocardial infarction, stable or unstable angina pectoris, hypertension or coronary artery bypass)
Life-threatening cardiopulmonary problems (e.g., severe sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy)

Hi Dan -
You definitely shoulw work through the appeal process as you should be able to build a case for yourself.  I previously worked in a bariatric practice and the big comorbidities that insurance companies typically look for are diabetes, hypertension (high blood pressure) or sleep apnea.  With your hypertension, hopefully that will help you to justify the surgery.  Put up the battle Dan, you are worth it! 
I wish you the best of luck! 
Warm Wishes,
Kim

i am currently in appeal.  they say a lot of the time they will deny people on the first try,  lots of people just give up,  that's what they want you to do.   If you have bmi >35 with co morbidities then you should qualify,  fight them  that's what i'm doing,  good luck

Thanks for all the great input!!! I'm just waiting for the denial letter to arrive and then on to the appeal process. The good news is that we appeal with my wifes employer rather than the insurance company. I'm confident I'll be approved.

Thanks again!!!!!

Good Luck Dan,  I wish you the best!
  My family and I have UHC, Choice Plus too, yet they have told me that  we don't have bariatric coverage.  Does this plan vary from state to state.  I am in Georgia.  Or is it you just should file anyway even if it is not.

Tora