Denied by UHC w/ BMI of 39 and 2 co-morbids

[MinkysMom 0]

Hi, I'm new here and but have been reading the forums for awhile. I just found out that UHC PPO denied my approval for LAP-BAND®. My doctor's office and I knew that UHC had a requirement of a BMI of 40. However, I was only a BMI of 39 with co-morbidities of Type 2 diabetes and hypertension. We thought we had no problem and that UHC would take the 2 co-morbidities into consideration. But it was flat out denied. My doctor's office even asked for a peer-to-peer consultation with my surgeon and UHC's doctor to discuss but UHC said there is no wiggle room for that either.

Has anyone experienced this before with my same conditions? Did you appeal and get approved? Do you suggest I work with an Obesity Law advocate to help me appeal? I really think I have a good case. I'm trying to stay positive with all this. I really don't want to raise my BMI to 40 as I feel that will really harm my health even more due to my current medical conditions. Afterall, I strongly feel with an amazing tool as the LAP-BAND® it will help cure me of my diabetes and hypertension.

Any insight is great appreciated!

[lisw55 0]

Dear FissyLove,

I was initially turned down with a BMI of 39 and co morbiditiies. Then I spent the next 6 weeks feeling sorry for myself. Do your self a favor by skipping this part and sit down wth all the facts to write a rebuttal letter to the insurance company that includes everyting you have done to get ready for the surgery to include hard facts regarding how much money they have already spent on your care and how much they could potentially spend on you over the next 20 years for your care if you do not have the surgery. Writing this letter took one week and was the most important step in my journey. I had just lost my youngest sister to heart failure that began due to morbid obesity. The insurance company was not going to take charge of my life. Instead I took charge and am now a healthy person.

Stand up and take charge and do not let these bullies keep you from being healthy. IMO, you do not need a lawyer until all your options have been exhausted.

God Bless you!! Now go out there and get your lapband surgery approved!!

Leona

[MinkysMom 0]

Thank you so much for that, Leona! May I ask what exactly you included in your letter to get you approved. Also, who did you exactly send it to? The care coordinator? I seem to get the run around from insurance so I want to make sure I get it to the right person. I have a strong case with my 2 co-morbids. Also, how long was the process after you sent that letter? Was it with the appeal? Sorry so many questions but I want to move on this quick.

Last October, I was even hospitalized for chest pains which concerned the doctors due to my hypertension. Turned out everything was fine and I ended up paying a huge amount for an overnight stay, testing and lab work. I'm tired of all the doctor visits, medication, and blood work I continuously have to do because of my diabetes, hypertension and now high cholesterol. I'm in my early 30s and taking 5 different medications to treat my conditions. I know the lapband is the best thing I could do to help with losing the weight and finally get off all these meds.

[Bella Luna 1]

I wonder if you could submit the request again. I really have no idea about insurance stuff. But I had a BMI of 39, so I purchased leg weights with removable weights took out two one pound weights and stuffed them in my bra and magically my BMI was 40.

I would do what ever I had to with a BMI of 39. I obviously don't know your health, only you do, but for me if just increasing my weight by a few pounds meant that I could get the surgery the I would do it. I would consider which is more dangerous: gaining a few extra pounds (either actually gaining more weight or with the assistance of external weights) for a month or two in order to get the lap band and reach a healthy weight or not gaining the few pounds and trying continue fighting the bulge for years to come.

I hope this isn't a weird response, it's just my thoughts. I hope your insurance will see the light of how you will benefit from this. Good luck, it's never fun dealing with insurance.

[Llyra 3]

Weird? I think you are a genius. Heck yeah, wear your heaviest clothes and all the gold jewelry you can stand up under for the weighing. This arbitrary discrimination of anyone under 40 BMI is for the birds. God bless my insurance for finally approving my surgery at 36 BMI (or was it 35 or 37? Under 40 anyway). My arthritis is much improved and me GERD is gone.

Hang in there, Fissy, and advocate for yourself for all you are worth.

[spoiltmom 44]

I wonder if you could submit the request again. I really have no idea about insurance stuff. But I had a BMI of 39, so I purchased leg weights with removable weights took out two one pound weights and stuffed them in my bra and magically my BMI was 40.

I would do what ever I had to with a BMI of 39. I obviously don't know your health, only you do, but for me if just increasing my weight by a few pounds meant that I could get the surgery the I would do it. I would consider which is more dangerous: gaining a few extra pounds (either actually gaining more weight or with the assistance of external weights) for a month or two in order to get the LAP-BAND® and reach a healthy weight or not gaining the few pounds and trying continue fighting the bulge for years to come.

I hope this isn't a weird response, it's just my thoughts. I hope your insurance will see the light of how you will benefit from this. Good luck, it's never fun dealing with insurance.

I have to say that I agree with this also. I drank lots and lots and lots of Water before any of my weigh ins. I also wore jeans and sneakers rather than capris and sandals. It won't take much to add just 1 BMI point.

Good luck

[lisw55 0]

Minksymom,

I will find my letter scan and send it to you. Some kind soul sent me a copy of their letter, so I had a general idea of what I needed to address in the letter. It was an appeal letter and took 15 days for approval. I called to check on the progress and could not believe the guy when he said it had been approved. I asked if he would check it again to make sure the approval was under my name. He just laughed and told me to trust him that it had been approved. Then I was nuts for 3 weeks until I got the letter in the mail. By that time I had the surgery scheduled and was ready to go for it! It may take me a few days to find the letter and scan and send it. I'll need you email. Leona

[MinkysMom 0]

Thank you so much everyone for your insight and support in this. I've been bummed and trying to figure out what my next plan of action is. I was denied last Thursday and still waiting for UHC to send my denial letter which will give me instructions on how to appeal. Leona, you are an angel and thank so much in advance for sending that letter so I can help plead my case to get approved. If all doesn't go well, then I'm definitely wearing some weights at my next eval. Thinking positive!!!! I will get this done! =)

[Keia 4]

Minksymom,

I will find my letter scan and send it to you. Some kind soul sent me a copy of their letter, so I had a general idea of what I needed to address in the letter. It was an appeal letter and took 15 days for approval. I called to check on the progress and could not believe the guy when he said it had been approved. I asked if he would check it again to make sure the approval was under my name. He just laughed and told me to trust him that it had been approved. Then I was nuts for 3 weeks until I got the letter in the mail. By that time I had the surgery scheduled and was ready to go for it! It may take me a few days to find the letter and scan and send it. I'll need you email. Leona

Oh my gosh, I could just cry. I never considered UHC denying me. I don't remember what my BMI was, I do have high blood pressure. Now I'm really freaking out. I have two more classes to go; Oct 14 is my last one. My co-worker is waiting to hear from them, he finished last month.

Best of luck to you. Please let me know how it goes.

[phershey 1]

hi everyone! well i just found out that on friday i was denied by uhc :thumbup: i am so sad my plan covered 5 year weight history with a bmi of 35 with 2 co-morbids or 40 without any comorbids. on the same day i went to meet with my surgeon and my bmi was 35 ( i have more than 2 co morbids) then an hour later i went to band class and my bmi was 34.8 so when it was submitted to my insurance company the nurse at uhc looked at it she denied it because of the 34.8...i have know idea what to do any help/advice?

[Cocoabean 430]

hi everyone! well i just found out that on friday i was denied by uhc i am so sad my plan covered 5 year weight history with a bmi of 35 with 2 co-morbids or 40 without any comorbids. on the same day i went to meet with my surgeon and my bmi was 35 ( i have more than 2 co morbids) then an hour later i went to band class and my bmi was 34.8 so when it was submitted to my insurance company the nurse at uhc looked at it she denied it because of the 34.8...i have know idea what to do any help/advice?

Was it on the same scale? I'd appeal based on the fact that most scales are not calibrated and on the surgeon's scale your BMI was 35 and they arbitrarily chose a scale that wasn't.

Ask for them to weigh you again. Be sure to be in jeans and sneakers.

I, personally, don't agree with the ankle weights. I feel that to be fraud. My opinion only for what it is worth. I'd be horrified if I got on the scale and the weight was noticed. :thumbup:

Also, did they check your height? As we age we tend to get shorter, an inch can make a big difference in BMI when you are talking 2/10 of a point!

[phershey 1]

i am going to appeal it. the doc office is closed today so i cannot get a hold of them and i have to drive 45 min away to get weighed...but will do it in a heart beat! on my appt day i did not eat anything all day because i had to get up early in the morning and get on the road i know that is no excuse not to eat but i always seem to run late in the mornings specially when i need to be somewhere on time lol also wore a light shirt some capri light weight shorts and sandals but they made me take my sandals off. i really hope that they look at it again and approve it.

[phershey 1]

so i went to get weighed in this am and my bmi was 36.4 so i hope when the surgeons office re-submits my info they approve it! i did wear jeans and a sweater lol. does anyone know how it works when they re-submit the updated info back in? do they just send in the current updated bmi? or all of the medical records again? i just hope that this will be it and they don't try to find anything else.

[Cocoabean 430]

so i went to get weighed in this am and my bmi was 36.4 so i hope when the surgeons office re-submits my info they approve it! i did wear jeans and a sweater lol. does anyone know how it works when they re-submit the updated info back in? do they just send in the current updated bmi? or all of the medical records again? i just hope that this will be it and they don't try to find anything else.

Yay! Glad to hear they are re-submitting it! I don't know the answer to your question. But it sounds like the surgeon's office is hopeful, else they'd not resubmit.

Do you know if they are saying the first submission was an error or is it an appeal? I know when I was denied, my denial letter explained the appeals process. Sounds like your situation is a bit different.

Seems to me, my opinion only, that if they are saying the other weight submitted was an error, then it should not matter if it is on record.

In my case, I asked what happens if after I am approved my BMI dropped below 35, would I be canceled. He said no, once I was approved, I was approved. Not to worry.

Keep us posted!

[phershey 1]

Yay! Glad to hear they are re-submitting it! I don't know the answer to your question. But it sounds like the surgeon's office is hopeful, else they'd not resubmit.

Do you know if they are saying the first submission was an error or is it an appeal? I know when I was denied, my denial letter explained the appeals process. Sounds like your situation is a bit different.

Seems to me, my opinion only, that if they are saying the other weight submitted was an error, then it should not matter if it is on record.

In my case, I asked what happens if after I am approved my BMI dropped below 35, would I be canceled. He said no, once I was approved, I was approved. Not to worry.

Keep us posted!

cocoabean i think you are about the sweetest and most helpful person! thank you so much for all of your advice! it is so nice to have someone who knows what i am going through. well i called and they said that i was denied so i asked why and they said it was because of the bmi that was 34.8 but they didn't even look at the one from the surgeons office on the same day i weighed in it was 35 they where at 2 different offices the 34.8 was from band class and the 35 was from the surgeons office. so i went back to the clinic where i had the lowest bmi to re-weigh and it was 36.4 (when i got the news i was so sad we where camping so i ate anything that i wanted a lot of dutch oven cooking)

i just received the denial letter in the mail today and the thing just says that my plan excludes it. but i think they are saying it excludes it due to the 34.8 bmi that they saw. they told me that on the phone. but not in the letter. did you write them a letter? that is what i am having a hard time debating on...or do i just let the doc office do it? they are not going to re-submit it until tomorrow that is when the nurse is in so i am going to talk with her in the a.m.