UHC Denial

[Texas Teacher 0]

I am hoping for some guidance from those much more knowledgable than me :help:...

I received a call from my surgeon saying that UHC had denied my pre-approval. As of right now we are waiting for the letter with the reasons, etc. so we can begin on the appeal process.

However, before I even went for my initial consult I contacted UHC to see if it was covered. I was told that there was not an exclusion, but that I would basically have to have all my ducks in a row to show medical necessity for it to be approved. I spent the next month gathering every medical record I could find proving the necessity and submitted it to the surgeon. He reviewed everything, said I was definitely qualified, and said he expected no issues with the insurance company. Then comes the denial.

After hearing this, I went to the website to see what I could find, and found this exclusion...

The following services are not covered:

Weight loss programs whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded.

I am so depressed about the entire thing and am not sure whether or not I am wasting my time. If there is a chance, I will definitely keep trying, but if it is pretty much hopeless, I don't want to get my hopes up again just to get another letdown.

So, what do you guys think? Is this the exclusion that will prevent my insurance from paying?

BTW, for those who have UHC, I found this info under "my coverage and costs" in the "Special Services" section at the bottom under "reconstructive procedures".

Basics about me:

5'4" -- 220.5 lbs -- BMI 37.6

sleep Apnea, High Cholesterol, Asthma, Fluctuating BP, Lifetime Member of Weight Watchers , chronic back pain/muscle spasms, plantar fasciitis, borderline diabetic

Thanks for any advice you can offer!!!

Renee

Richmond, TX

[Ladyred 0]

Renee,

I hope you dont get too depressed by what I say next but please investigate this more. I am only adding my 2 cents. I too have UHC. My daughter also has UHC at her employment. I have a friend that works with claims for a major insurance company and this is what she told me. Although the three of us have UHC there are 100's of policy's written based on what your employer chooses for each inusurance company. Often larger employers has better policys. My daughter works for a midsize company in DFW and her UHC will not cover bariatric surgery. My company is rather larger (coast to coast) and allowed it in our UHC policy if you qualify. Since so many people have taken advantage of it these past years at my company ( my conclusion) they are are discontinuing bariatric coverage Jan 1, 2007 for OUR policy. It does not mean everyone with UHC will have theirs discontinued. In the past I have heard UHC gave easier apporvals for bariatrics than companies like Cigna. Two of my friends have been jumping through hoops with Cigna. ( months of counseling etc). Your doctors office may be giving you information based on what their experience has been with UHC patients. They just had better policy coverage per their employer. Do some more checking before you give up.

Good Luck!! I hope it all works out for you.

[ladysplenda 1]

Both my daughter and I got turned down three times. They want you to give up. Do not do it. I was told if they turn you down beyond three times you can turn them in for a investigation / review insurance board and they do not want that. Forth time was a charm. I had to have 1 year supervised weight loss and a mental health evaluation and of course two major health problems.

I now weight 157

Do not give up.

[anewvue 0]

The following services are not covered:

Weight loss programs whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded.

Let me start off with, I am not an expert either. Now, the exclusion listed above is not for lap band. The above exclusion is strictly for a weight loss program that would include, a physician followed diet plan, prescribed diet pill, weight watchers, and others like this. You need to look for an exclusion in your policy under bariatric surgery. It should tell you there if it is a "direct exclusion" or covered if proven to be a medical neccessity.

You should appeal this immediatly. Also, you may want to check with the surgeons office, if they listed morbid obesity as the primary diagnosis, there is a good chance it was kicked back.

Most insurance companies follow the medicare guideline as far as the approval for a medical neccessary surgery. Medicare at this time states that your primary diagnosis cannot be morbid obesity. It has to be a co-morbidity and then the surgeons office can follow with a morbid obesity diagnosis.

The key to this is discussing it with the business office of the surgeon. Alot of the time they can resubmit correctly and you will not need to fight an appeal.

[Texas Teacher 0]

I got my official letter and it stated...

" I have determined that at this time morbid obesity surgery is/are not a covered benefit under the benefit plan. This determination is based upon the following plan language, found in Intranet Benefits at a Glance in the section entitled "Morbid Obesity":

"The following services are not covered: Surgical and non-surgical treatment of obesity, including morbid obesity." "

They also gave me information about how to appeal and forms to request an independent review.

Do you think I have a chance at all? I'm not sure the business office at my surgeon's has much experience in getting these approved. Any advice? I have considered writing my own letter listing all the co-morbidities, etc, but didn't want to create any additional confusion.

Thanks!

[Carlene 12]

"The following services are not covered: Surgical and non-surgical treatment of obesity, including morbid obesity." "

They also gave me information about how to appeal and forms to request an independent review.

Do you think I have a chance at all? I'm not sure the business office at my surgeon's has much experience in getting these approved. Any advice? I have considered writing my own letter listing all the co-morbidities, etc, but didn't want to create any additional confusion.

Thanks!

This is going to be an uphill battle, since WLS, even for morbid obesity, is specifically excluded. I don't personally know anyone who was approved when the policy contained a specific exclusion like this one.

But the appeal process is free, so I would definitely take advantage of it. I had to appeal twice to get my DH's fills paid for (UHC), even though they paid for the surgery and the first year of fills with no problem.

Sometimes the people you get on the phone are morons. I had one young woman "explain" to me that my husband's fills were no longer covered because "he is no longer morbidly obese". "And you would know that how?" I asked her. Her answer was because he had Lap Band surgery! Somewhere a villge is missing its idiot...obviously.

[MimIN 19]

I am so sorry you are have to deal with this. denials are so stressful and discouraging. I too have UHC and your story is very similar to mine. I did not have a copy of my certificate of coverage and relied on calling UHC and asking if lapband was an EXCLUDED procedure under my group plan and I was told it was a covered benefit if deemed medically necessary.

I too went through all the motions of gathering all the documentation the asked for and 3 weeks after I submitted to insurance for pre-determination I was denied based on exclusion. I got in touch with my company's UHC account Rep via email and had her admit in writting that it was their mistake. I had everything documented including the reason I did not have a copy of the certificate of coverage is because UHC had not given it to my HR department yet (we had newly switched carriers).

Although I had all this documentation I was denied on the first appeal. I consulted a lawyer who thought I had a case and I took it to a second appeal hearing. I was given the opportunity to state my case, spoke with the hearing board and actually ended it feeling very positive. 5 days later I received another letter and again I was denied stating it was an exclusion and it was not their responsibility to tell me what is and isn't covered under the plan. At this point I gave in and went self pay but I did submit to the state because they should not be allowed to get away with treating people like they do.

My best advice is to get a hold of the certificate of coverage (not what they have online, it is a 40+ page document your employer should have) and analyze it, document everything and get names of everyone you speak with. Keep going if even in the end it doesn't work out because you never know, you may be the one that beats them at their own game.

[Jimboss 0]

Texas Teacher, I'd like to also say, "don't give up!". I started my Quest with my insurance company in July 05. I kept after them even after being denied several times. Finally, in Sept 06 they gave in and agreed. My banding was on Oct 02, 2006 (I figured I'd get it done before they changed their minds!).

My weight at the end of Sept 06 was 324. Surgery date it was 319. Today I am at 288 and loving it! Don't give up Texas Teacher! Good luck and best wishes!

jimboss01@yahoo.com

[tonya66 13]

I have UHC too. I have my 1st appointment with the doctore on 11/22 and they will file my insurance. I'm so scared they are not going to approve me. When I called them and asked them if they covered it, they looked it up and said my only qualification was I must have a BMI of 40. So you would think it would be easy, so we'll see what happens.

I have heard of so many people being denied and they appealed and won, so don't give up. You deserve this!

[Texas Teacher 0]

I called customer service again today to attempt to obtain a little more information. First, I specifically asked if CPT Code 43770 is a covered. I was told that it WAS covered pending "clinical review". This is exactly what I was told the first the first time I contacted them PRIOR to my initial consult with the surgeon (I didn't have the CPT Code then.). I then asked if they could give me specific information about why my pre-cert was denied due to an exclusion when I've been told twice that it IS covered. She attempted to locate information, but she was unable to find anything that would indicate why this happened. So, she submitted a request for review of my case, asked that the person in charge contact me personally by telephone AND to send the specific explanation for the denial in writing.

I'm not getting my hopes up too high, but wish me luck anyway!

[sheilamj1fan 2]

Hello everyone,

I have UHC too and when I called about a month ago I was told it was covered, only if I met the criteria. So after seeing my my primary care physician, he agreed and wrote the reccommendaton letter. I have all the necessay paper work, so I hope I am approved. Good luck to everyone that is waiting for their approval.

Be BLESSED!

[tonya66 13]

hmmmm, what is your BMI? I know BMI has a lot to do with it. just don't give up, thats what I did, I gave them my code. I sure hope they don't turn me down, I'm so nervous about it.

[carolel 0]

Hi TexasTeacher,

I'm a Ga. teacher and UHC denies all requests by teachers that pass across their desks here in Ga. It's bad but there is an exclusion in our policies. I self-paid since many teacher friends had already been thru the hassle. My doctor also said that he had never had UHC pay for surgery for a teacher.I just wanted to get it done an dget on with my life. We took out asecond mortgage on our home. At least it's tax-deductible and I can write off the entire surgery cost this year.It's the best thing I've ever done for myself.

Good luck.