Need Help Understanding United Healthcare Policy Wording

[Watermelon 0]

I have my consulation with Dr. Jayaseelan this Monday, but I'm not sure if my insurance United Healthcare will cover.

Here's the wording which I don't understand:

Weight Reduction or Control. Adjustable or vertical banding not covered unless Preexisting anatomical or health conditions preclude gastric by pass. Gastric bypass or biliopancreatic diversion are covered under Care Coordination Guidelines.

What preexisting anatomical or health conditions preclude gastric by pass?

Any help you can provide is appreciated.

T.

[the best me 6]

Sounds as if you have a fighting chance. Alexandra will no doubt be able to give you good direction, but I'm sure others will be able to advise as well. Good luck! Go get 'em!

[Alexandra 55]

Kathy, lol...

TLBowe, there are all kinds of medical conditions that might preclude RNY surgery and make banding truly the medical preference. I'm wondering if that's standard language, though, because UHC is usually known to cover banding pretty readily.

You should ask your doctor's office about this. If you have relevant medical issues it's your doctor's job to put that information in the request for precertification. I'm sure they've run across this before. But even if you are healthy, they should submit the request anyway if banding is the procedure YOU want. Just list all the reasons why it's right for YOU in your letter, and all the reasons why RNY is not. Psychological and emotional reasons are just as valid as medical ones.

[Watermelon 0]

Thanks for your replies!!!

I know of several employees at my company who got the lapband prior to 2005 and it seems that the company changed it's policy. Right now, there are a few people I know who have been declined and given the option for gastric bypass, but again who wants to be cut to pieces.

I know lapband is the option and understand that I will probably have to fight for this procedure.

T.

[LadyTee 0]

What state are you in? I also have UHC. I live in Indianapolis, Indiana.

[ReneBean 3]

If they will approve you for By-Pass - then you can fight them for the LapBand procedure. I had to go all the way to the State Insurance Board for Independent Medical Review - but I won...

PM me your e-mail if you want to see my appeal letters.

Good Luck!!

[Wheetsin 714]

Yep, they're basically saying they will only approve lap-band if there is some physical reason why you cannot get gastric bypass, e.g. a birth defect that would make gastric bypass impossible, but banding an option.

Odd, I have UHC and they covered gastric bypass & lap-band equally when I first called them to ask. They're one of the more band=friendly carriers out there.

[Watermelon 0]

I'm in Dallas, TX and work for a hospital. Had a consultation with the internist today and she stated that they sometimes have problems with my employer. Sometimes they approve right off the bat and sometimes they decline. However, when they do decline they normally approve in the appeals.

I was happy to hear that but for some reason I have a feeling they are going to decline it.

I've spoken with my insurance company 3 different times and was told 3 different things. So I'm not quite sure what the final decision will be.

T.

[ReneBean 3]

T - I sent my letters. Let me know if you didn't get them, or have trouble opening them.

:]

[skbishop78 0]

DId you find out about UHC, I have UHC and they are paying 90% no questions asked really. My surgeon got a pre-auhorization and that was it....I am in TN though, it may be different. They have several plans though, and different plans cove different things. I called everyday until I got my approval, it took them 2 weeks. I started the whole process on Jan 2, and am getting banded On Feb 20th, I thought that was pretty quick. Stay on them....call the back of your card, and speak to someone, they can tell you 100% without question what you are covered for. Good luck!!!

[Wheetsin 714]

What UHC plan do you have? Mine is covered at 100%, but if I have to stay overnight there's a $250 inpatient deductible (who cares?!)

[NurseTeresa 0]

I am so jealous. I also have UHC and they won't pay for anysort of weightloss at all not pills not diets and definitely not WLS. So much for being a nurse and working at a hospital. My insurance sucks. Where do I go from here? Can anyone tell me? I am single mother and barely make it now but need this surgery to make sure I can live many many more years. My weight is going up as well as my age. Any help would be greatly appreciated!

[Alexandra 55]

NurseTeresa, it sounds like you have a large-group policy, the provisions of which may be dictated by your employer. Can you appeal to your HR departmanet?

Or, barring that, if your hospital does banding is there some sort of employee dicsount? (That sounds funny, but I'm being serious.)

[NurseTeresa 0]

Alex,

Thanks for the wonderful thoughts.......I asked about the discount the answer to that one was ummmmmmmmmmm NO. I then asked about payroll deducting it..........the answer to that was NO!! If it can't be paid for in 2 payments then we won't do it. We also asked about going through HR and having it or should I say tryint to have it appealed and decided on through them. They replied with a We just got anthem back so its going to be awhile before we take on something else soo big. Too a few of us the only thing we see big is our selves. Any other suggestions would be greatly appreciated. Maybe in a year or so they might include it but I am to the point I don't feel I have another year with all this extra weight! Why have a service offered at your hospital and the employees can't benifit from it?

[skbishop78 0]

Hey, I have UHC with Best Buy (DH is Manager at BB). We had 5 plans to choose from and I chose the 4th plan knowing that I wanted this surgery and it paid 90%. I felt lucky getting that...wow i couldn't imagin 100%!!!

NurseTeresa, I am so sorry to hear of the trouble you are having. I know you are a full-time nurse and mom, but if you could swing a part-time job at somewhere that offers insurance like Best Buy then you could get the surgery and have it paid for 90%...I know that sounds crazy, but it would be worth it in the long run to work a couple of months to get approved and get the surgey done and then quit. Sounds mean, but desperate times call for desperate measures. Let me know how it goes!