New In The Neighborhood...any Advice Would Be Great

[jwade77 0]

Hello All!

I started my gastric sleeve journey in January of this year. I have United Healthcare insurance which covers gastric sleeve. My BMI is 38. According to my policy, they will cover it if I have a co-morbidity.

I went for my initial consultation at the South Carolina Obesity Center here in Columbia, SC. Dr. Givens recommended the gastric sleeve. Two weeks later I had a sleep study done and low and behold I have sleep apnea. So there is my co-morbidity.

I was also instucted to be on a 3 month supervised diet. I went to every weigh in appointment and all the classes.

On April 17th it was my pre op diet appointment with the dietician. My last hoop to jump through. At this point I am thinking...heck yeah!

Just got a call today that UHC has denied my surgery due to the fact that my BMI is too low and I do not have a co-morbidity. I informed the pre-determination counselor that I do in fact have sleep apnea. She replies that she sees that and doesn't know why they have denied it but a peer to peer consultation is suppose to take place this week between UHC's Medical Director and Dr. Givens.

Well I am a little down in the dumps. I know that it doesn't mean 100% no but its not a yes either.

Has anyone else had any experience with this? Is it normal procedure for United Healthcare to deny on the first go round? Also, does anyone know if the peer to peer meeting usually goes well?

Any advice would be greatly appreciated. I am really trying to keep a positive attitude.

Thanks in advance!

[Sammi25 18]

Hi, I have heard a lot of people have to resubmit their info to insurance, as they were denied the first time. In your case it sounds like it may just be a miscommunication or maybe some pages didnt get faxed through to insurance. I would definitely resubmit! good luck and keep us posted!

[jwade77 0]

Thanks!! I will do that and I will keep everyone posted. Maybe what I go through will help out somebody else!

[Artsy 48]

I am 37.5 BMI with only sleep obstruction apnea. I've performed all tests required by surgeon & UHC--blood tests , stress tests, heart ulta sound, sleep study, psychologist exam. I'm also just under 5 feet tall. My case worker is submitting my paperwork today to UHC. Hoping for May 7 surgery.

[cookies 56]

I sometimes wonder if insurance companies deny the first attempt on purpose, hoping that people won't resubmit or appeal the decision.

I'm sorry to hear about your difficulties. I'm with Dr. Strickland at the same obesity center, but I'm self-pay so no help on that front, I'm afraid.

[jwade77 0]

Good luck Artsy! Let me know how it goes!

[pstreater06 2]

Stay positive! I was initially denied, but kept the process going and crossed every T and dotted every I. I was sleeved on 11/2/2011 by Dr. Antonetti through the same office. Today, I have lost 80lbs. since the surgery. The workers there were very helpful and helped me the whole way. Good Luck and stay with it!

[BKMama 179]

I have not had that experience, but I wish you the best of luck! I hope resubmitting works for you.

[jwade77 0]

Thank you everyone for all the words of encouragement! I really needed it today.

[jwade77 0]

UPDATE:

Peer to Peer was held and United Healthcare has upheld its decision. We are now in the appeal process. I am going to read up on this site to see exactly what I should include in my appeal.

[jwade77 0]

Well apparently it wasn't an appeal that Dr. Givens submitted. It was additional information. Well on 6/15 they approved everything but the actually procedure. So on 6/25, an appeal was sent in. I have 22 days to wait. Keeping everythhing crossed that it gets approved. I'm not giving up yet.

[Pre-OpLoser619 36]

F'in insurance companies! Sorry, but that just pisses me off. That any insurance company would deny if it's medically necessary is ridiculous! But they'll pay for you to be on 50 different meds and a c-pap, etc that cost them hundreds of thousands of dollars... I really hope everything works out for you!

[rayne7680 0]

I was denied twice by United Heathcare. I appealed twice and then on my final appeal I was approved. My BMI was over 50 so I clearly met all criteria. Hang in there! I was sleeved 7 days ago!!!!

[geno5150 168]

Keep in mind, the insurance company sees you as a bunch of ICD9 codes so one wrong number can trigger a denial. This is why it sometimes takes a manual review to figure out what the issue is.

[jwade77 0]

I GOT APPROVED! Wrote my appeal letter and just heard today that I have been approved.