United Health Care

[Ms. E 5]

Good Morning everyone, I have a question I am stuck and don't know what to do. My husband went to see the Doctor, he claims my husband is a perfect candidate for the sleeve; He has a BMI of 42, High Blood Pressure, sleep Apnea, and everything else that comes with it. The Insurance rep at the doctor's office looked over his chart and said that even though he has 4 years of a BMI over 40, UHC requires his BMI to be over 40 for 5 years therefore UHC would deny him. She is refusing to send UHC his information and request for surgery saying he has to wait until next year.

So this is my question, can we send his file to UHC and try to get approved on our own, or should I just wait until October for my open enrollment at work and change insurance companies over to Aetna who only requires 2 years of an BMI over 40?

Thank you for your help.

[former_vbg 198]

The very first thing I would do is call your insurance company to see if what that insurance coordinator says is correct- that sounds a bit odd to be to require that length of time for a high BMI.

Second, I don't know of a single insurance company that will allow you (the insured) to submit for pre-approval of any surgery. Someone who works "in the biz" can surely correct me, but I had thought about that myself when i had some issues with inept ins. coordinators and was told I couldn't do it- only the Dr.'s office could submit it.

Third, if you find out from your ins. company that your husband IS within the guidelines, ask them if their policy bulletin is posted online and then I would PROMPTLY fax or email that to the ins. coordinator at your Dr.'s office and explain to her that she was MISINFORMED on your insurance guidelines.

You have to be your own advocate - or in this case since you are helping your DH, then you must help him be his own advocate and not let others determine your future or his.

I had to switch surgeon's just 2 wks before being scheduled for surgery w/the first surgeon- already had the pre-approval without doing the supervised diet because I met my ins. policies requirements for having a Revision under the clause of complications.

When I switched surgeons, the IDIOT insurance coordinator kept telling me that even though I already had a pre-approval I would still have to do the 6 mth supervised diet. She literally argued with me and I told her she was wrong. She finally caved and made the request to switch the approvals over but told me they would still deny me on those grounds.

HA!!!! She was wrong and she had to eat her words. She wouldn't return my calls after all that was said and done. I didn't care, she kept saying, "I've been doing this for 10 years, I think I know how to do my job.". Yeah... whuuuutttt evvvvvaaaaa....

So, at the end of the day, don't take the final word from ANYONE unless it's from the result of you making the contact with the final decision makers whether it be your ins. company, etc.

[peacequeen 434]

I have UHC ChoicePlus and they said they require the 5 year morbid obese record. I'm worried because mine has only been this high for about 3 years. My bad that I was just severe obese before that *sarcasm*. I can't really get excited about all of this or take it serious because it's just a waiting game for me right now. I think I'll post the question to everyone,,how many out there were approved with UHC's 5 year bmi requirement.

[Janae 12]

Go to UnitedHealthcareOnline.com. Click on Medical & Drug Policies and Coverage Determination. Click on Bariatric Procedures. This is the criteria used to determine coverage, unless you plan has a specific rider excluding coverage altogether (call the pre-authorization telephone number on your insurance card and ask this question)..

If your husband meets all of the criteria, gather up all of his medical records and submit to UHC with a letter that addresses how he meets each criterion. Indicate who his surgeon will be and that they refused to submit the request.

If denied, appeal the denial by requesting that a board-certified bariatric surgeon review the case. Ask them to explain why it was denied when all stated criterion were met.

Good luck!

[peacequeen 434]

The only problem is there are several different types of UHC and an employer can set his own requirements as well.