UHC BMI REQUIREMENTS KEEP CHANGING!

[2bfit 62]

Has anyone heard of UHC *** requiring a BMI of 35 or over with one comorbidity for surgery? I was denied for the surgery stating that I need to have one comorbidity to qualify.

However, when they first denied me for my consultation they indicated that I had to have a BMI of 40 OR a BMI of 35-39 with a qualifying comorbidity. That was the letter from the medical group. When I appealed the consultation denial to the insurance company I received a letter from UCH stating the same thing BMI of 40 OR a BMI of 35-39 with a qualifying comorbidity.

Now all of a sudden the game has changed? They clearly left out the part of the BMI being 40 or over on my most recent denial for the actual surgery. I have 2 documents from them on their own letterhead stating that a BMI of 40 would qualify if medically necessary. I guess that's what I will have to go after them with if my appeal for the surgery does not get approved again.

UHC has my appeal as of right now so I will probably have to wait for 30 days until I know something. Right now I am finishing up the 3 required visits with the NUT and I did meet with their weight doctor as well. He wants to put me on a Medifast program but my NUT is absolutely against it. She is going to document her reasons why going on Medifast again will not work for me. So at least I have her in my corner.

So now I sit and wait again....

[M2G 1,836]

Now all of a sudden the game has changed? They clearly left out the part of the BMI being 40 or over on my most recent denial for the actual surgery. I have 2 documents from them on their own letterhead stating that a BMI of 40 would qualify if medically necessary.

Here is a portion of my other post just in case you don't see it addressing what the requirements were for ME and MY PLAN!

Also our plan stipulated that it was BMI of 35-39.9 with at least ONE co-morbidity (and it actually spelled out which ones would qualify as a co-morb) OR a BMI of 40.0+ or greater, no co-morb needed. I fell into the 40+ category and my husband did too (just barely) but he also had a covered co-morb so he would have been approved even if his BMI had slipped below 40, whereas my BMI HAD to stay above 40+ the entire duration of the 6 months of check-ins. My UHC nurse case manager made sure to spell that out for me that I could NOT slip below 40...I appreciated her honesty. It is ALSO part of the reason that I did not do any type of pre-op diet, of course I could have lost a few lbs since my BMI 4 points above the danger line, but I wasn't planning on risking denial over my BMI!!!

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BMI of 40 would qualify if medically necessary.

The last part probably all you need is a letter from your PCP stating that they THINK surgery is medically necessary...I had to get that from my PCP who was a willing partner in helping me get surgery...thank goodness!!

[juicycaboosey 0]

I was just denied by uhc because I needed to be at 40 bmi for 5 years. I linger at 38 bmi, sleep apnea and hypertension.

[Cerebus 2]

For my UHC plan to cover the sleeve, it was 35+ and a co-morbidity, or a BMI of 50+. "Luckily" I was in the 50+ category as I have no co-morbidities. They did waive the 5 year weight history though.

[lovealways 22]

My UHC plan is 35-39 bmi with one documented co-morbidity or a 40+ bmi with no co-morbities. Good luck in the process...I hope UHC is good with not throwing out too many hoops =\

[juicycaboosey 0]

Thank you for the positive thoughts!! Good luck to you too!!

[aworkinprogress 5]

Hi my Delta airlines UHC plan is 35-39 bmi with one documented co-morbidity or a 40+ bmi with no co-morbities. They do NOT pay surgeon fee and asst. surgeon fees tho ouch!