UHC - Now Approves VSG!!!!!

[tomandlu 0]

For those that have bariatric surgery benefits with United Health Care, they now approved Vertical Sleeve Gastrectomy!!!!

Hooray!!!!

Here is the language from their Bariatric Medical Policy, dated 12/20/2007 that was in effect before 9/17/2009:The gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic sleeve gastrectomy) when done alone and not a part of the full operation to complete a biliopancreatic diversion with duodenal switch is unproven due to inadequate clinical evidence of safety and/or efficacy in published, peer-reviewed medical literature.

Here is the language from the UHC Bariatric Medical Policy dated 9/17/2009: The gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic sleeve gastrectomy) when done alone and not a part of the full operation to complete a biliopancreatic diversion with duodenal switch (BPDDS or DS) is proven in adults for the treatment of clinically severe obesity as defined by the National Heart Lung and Blood Institute (NHLBI).

Hooray hooray hooray!!! I've been so busy doing research, drafting appeals and feeling frustrated and miserable. On Monday I am calling my surgeon back to get a DATE!!!

Luanne

[Malaika 50]

Tomandlu - welcome to the forum and that is FANTASTIC news - thank you for sharing -- I have UHC; unfortunately they have a restriction of not covering anytime of WLS - so I was a self pay and ended up going to Dr. Aceves in Mexicali because he was less expensive (and probably better than any surgeon here in LV). Hopefully one day all companies will chose not to have a WLS restriction on their policies. Baby steps I guess.

Let us know when your surgery is !

[tomandlu 0]

*sigh* I over looked this the first time I read the new UHC policy... It is wonderful, it recognizes the sleeve as proven. It now requires 6 months supervised weight loss, "

Additional Information

Patient selection criteria for bariatric surgery includes:

l Documentation of a structured diet program which includes 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.

"

... I have done that, I just don't have documentation - it wasn't needed before. I have two years on weight watchers except the records were tossed when I moved last year. I feel so.... defeated. I've been working on getting surgery since March (6 months 1 week). I have lost 30 pounds since talking to nutritionists... but it is not structured enough. I am soooooo.... defeated, frustrated, tired... this process is never going to end. Sorry for the whine folks, it has been a long few weeks of writing appeals - and when I thought I had won they throw another new hurdle at me that is going to take 6 months starting from now.

[schatzie 0]

Do you think they will pay for patients that had vsg before 9/17/09?

[tomandlu 0]

I have no idea. You can always submit, appeal...appeal... several levels of appeal. Heck, it's a lot of money, worth at least trying. Good luck! Let me know if I can help - I'd at least give it a shot.

Luanne

[Malaika 50]

*sigh* ... I have done that, I just don't have documentation - it wasn't needed before. I have two years on weight watchers except the records were tossed when I moved last year. I feel so.... defeated. I've been working on getting surgery since March (6 months 1 week). I have lost 30 pounds since talking to nutritionists... but it is not structured enough. I am soooooo.... defeated, frustrated, tired... this process is never going to end. Sorry for the whine folks, it has been a long few weeks of writing appeals - and when I thought I had won they throw another new hurdle at me that is going to take 6 months starting from now.

Call the WW in your area - main number - they keep those records for a while - so they may still have your's ... it's worth a try!

[akindofmagick2 0]

... I have done that, I just don't have documentation - it wasn't needed before. I have two years on weight watchers except the records were tossed when I moved last year.

Do you have cancelled checks? Credit card records? Can you get them? I've read elsewhere that that is considered proof of services.

My concern is this statement:

"....clinically severe obesity as defined by the National Heart Lung and Blood Institute (NHLBI). "

Is the NHLBI definition the same as the NIH definition? Off to research..

not that I'm gonna do the six month thing, tho. BTDT, many many times in my life. Heck, I've even tried hypnosis!!

Don't give up yet, tho - unless you paid cash...

Sheri

[tomandlu 0]

Thanks for the encouragement Sheri - yes, I am going to try that. Show them my 5 years of cancelled checks and my doctor's notes. I have also been sent to nutritionists 3 times - I am wondering what person in our shoes has not been on several "structure weight loss" programs before going for surgery? I'm not giving up, but I am mightily discouraged. I ended up taking two days off from work and just crying last week. I know, silly me....

I believe the NHLBI is a division of NIH. The new UHC policy, IMHO, is significantly better written and referered than the previous one.

Luanne

[twobluecats 1]

Grr! I am attending a seminar this Wednesday, and I know that our United Healthcare Choice Plus will cover weight loss surgery, but I forgot to ask about the presurgery requirements.

I attended Weight Watchers meetings from January through June this year, and I'm still involved with the online version. I wonder if WW records from that timeframe would be considered adequate?

I'll report back what I find out from United Healthcare tomorrow.

[lucygoose 0]

My husband has UHC through his retiremtent plan. I have called them 5 times to see what requirements were needed before I added myself to the plan. 5 times I specifically asked if there was a supervised diet requirement for any amount of time before surgery would be approved. 5 times I was told no. I sure hope the 5 different people I talked to knew what they were talking about.

[tomandlu 0]

The diet part is an interesting question. It has it in the new bariatric policy, but several folks have told me that that is something that is a part of the agreement between the company and UHC. As it turns out, my 2nd appeal was approved with out any additional requirements.

In the 'Coverage Rationale' section, it has the following that is new:

Additional Information

Patient selection criteria for bariatric surgery includes:

l Documentation of a structured diet program which includes 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.

l 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.

l Psychological evaluation to rule out major mental health disorders which would contraindicate surgery and determine patient compliance with postoperative

follow-up care and dietary guidelines.

[twobluecats 1]

Great news Lu! I'm hoping to get more information on Wednesday. In the meantime, I've been getting my doctors (or attempting to) records together, and I confirmed with WW today that my time with them, including weigh ins were from January 13, 2009 through July 21, 2009--just over six months. Not sure if it will help, but with my BMI at 41-42, type II diabetes, high blood pressure, and plenty of years of high weight history, I'm hoping I get approved.

Now if the butterflies would all fly in the same direction in my stomach, I'd feel better! It's a hard decision to make.

[Bambi 0]

Oxford doesn't cover as of 8/17/09 - Due to insufficient clinical evidence to support medical efficacy, the following will not be reimbursed by Oxford:

• Gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic sleeve gastrectomy) when done alone and not a part of the full operation to complete a biliopancreatic diversion with duodenal switch
  

[longhorn 11]

twobluecats....did you learn if you are covered? I just received a denial letter from UHC. But I do not yet have the specific reasons why. I know my company covers lap band and RNY. I'm hoping this can get cleared up in my favor. Have to wait until Monday to call UHC and get more info.

[LittleLadySky 0]

for those that have Oxford/ UHC I had found this information...hope this help many of us having issues with Insurance:

As of October 1, 2009 United Healthcare along with Oxford insurance companies cover the Sleeve Gastrectomy procedure. According to their policy "the gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic sleeve gastrectomy) when done alone and not a part of the full operation to complete a biliopancreatic diversion with duodenal switch (BPDDS or DS) is proven in adults for the treatment of clinically severe obesity as defined by the National Heart Lung and Blood Institute (NHLBI)."