United Healthcare Choice Plus requirements

 Typically, UHC requires a 6 month diet.  You need to look at your company's specific UHC policy.  My specific UHC policy did NOT require a 6 month diet.  

 This is what was emailed to me today from my employer. Now, my question is....I've done the 6 month diet, but it was through my family Doctor. All he had me do was a discussion about weight loss, diet, nutrition and exercise, then I came in once a month to be weighed in. Is that going to be satisfactory with what my insurance wants? I can't quite understand if that would work, or if I have to do WW or Jenny Craig or something along those lines. If someone could figure that out, I'd be super happy!!! I did do WW and it falls within the 2 years prior of surgery, but I didn't always go to the meetings and do the weigh-in, because the woman there was so terribly rude and sarcastic. She was the reason that I finally withdrew from the entire program. 

Bariatric surgery, as a primary treatment for weight loss is proven for the following:

 

I.                   Class III obesity (BMI > 40 kg/m²)

II.                A BMI of 35 kg/m² or greater with obesity-related co-morbid medical conditions including:

A.                Hypertension

B.                 Cardiopulmonary condition

C.                 Sleep apnea

D.                Diabetes

E.                 Any life threatening or serious medical condition that is weight induced

III.             Demonstration that dietary attempts at weight control have been ineffective through completion of a structured diet program, such as Weigh****chers or Jenny Craig. Either of the following in the two-year period that immediately precedes the request for the surgical treatment of morbid obesity meets the indication:

A.                One structured diet program for six consecutive months; or

B.                 Two structured diet programs for three consecutive months.

IV.             Completion of a psychological examination of the member's readiness and fitness for surgery and the necessary postoperative lifestyle changes

 

 

 

 

 

 

 

The following bariatric surgical procedures are proven in adults for the treatment of clinically severe obesity as defined by the National Heart Lung and Blood Institute (NHLBI):

 

·         Gastric bypass (Roux-en-Y; gastrojejunal anastomosis)

 

·         Adjustable gastric banding (laparoscopic adjustable silicone gastric banding) – See FDA section/information

 

·         Gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic sleeve gastrectomy)

 

·         Vertical banded gastroplasty (gastric banding; gastric stapling)

 

·         Biliopancreatic bypass (Scopinaro procedure)

 

·         Biliopancreatic diversion with duodenal switch

 

Plus there are other approaches approved

 

 

 

 

 

Patient selection criteria for bariatric surgery include (NHLBI, 1998):

 

·         Documentation of a motivated attempt of weight loss through a structured diet program, prior to bariatric surgery, whi*****ludes physician or other health care provider notes and/or diet or weight loss logs from a structured weight loss program for a minimum of 6 months.

·         Active participation in an integrated clinical program that involves guidance on diet, physical activity and behavioral and social support prior to and after the surgery.

·         Psychological evaluation to rule out major mental health disorders which would contraindicate surgery and determine patient compliance with post-operative follow-up care and dietary guidelines.

 

 

 

 

 

Most bariatric surgeons know what the insurance is looking for in regard to predetermination criteria.  It would make sense for  a predetermination to be completed as the plan only covers Morbid Obesity Surgery.

Just as an FYI, you don't have to have a myuhc.com login to get the medical policy from United HealthCare.  Hopefully this link works:
www.unitedhealthcareonline.com/b2c/CmaAction.do

Their medical policy was updated on July 1st of this year and does mention a 6 month dietary requirement, although our office has successfully appealed numerous denials where that criteria element was not/could not be met.  There are, as mentioned in other posts, plans where UHC acts only as an administrator and not as an insurer and some of them have requirements in their certificates such as a 5 year history of morbid obesity; age criteria (21 in many cases / 18 in others), etc.  Because of the dangers involved in waiting to have surgery and because the ASMBS does not believe the evidence supports these restrictions we don't believe that anyone is served by waiting to submit to insurance.  It is a trap that harms many people.  wlsappeals.com/insurance-traps-to-avoid/
Rather, people should get into the payer system, even if it is to get denied, so that they can appeal these unreasonable denials and, ultimately, get payers to change their medical policies (as is occurring in many places).
Hope that helps.