Help! New to site. Denied. UHC Employer Lifetime Max $15k? 5+yrs history

[Jordy423 0]

Hey all,

I need your assistance! I'm new to this site. My aunt had her VSG last August and looks amazing. I attended a seminar 3 weeks ago that my aunts surgeon asked her to speak and share her experience. She and my doctor recommended this surgery and I was so hyped to learn of this procedure, turned in my insurance information at the seminar and enrolled into "the program"

Thispast Monday was my appointment to go over insurance, and she immediately told me my UHC Premium PPO has a lifetime max of $15,000 and I must have a 5 year history in order to qualify. My out of pocket would be $3200 which is do-able... however the surgery will cost well over $15,0000 and I do not have a 5 year history My weight has gone up and down, up and down over the last 10 years, and I've moved so much within the last 5 years I didn't have health insurance for awhile and no record of 5 year history. My BMI is 39.5 now after losing 10 lbs due to new Migraine medication, (before it was 40.3) with multiple comorbidities (hypertension, high cholesterol, PCOS, foot pain/arthritis, GERD and urinary incontinence which is all new to me that started 2 years ago.)

I'm at a loss. The insurance nurse told me I need to find other insurance. Do I really need to find another job to get this procedure done? I had an interview with JPMorgan Chase last week who I believe goes through UHC as well, but the nurse believed they worked better. I don't want to risk getting a new job making less money, just to find out I'm denied.

I called the number on the back of my insurance card to confirm if this was in fact true, and they said yes and would have a bariatric case nurse from UHC call me within 5-7 business days... but they will probably just confirm this awful news that my employer is requiring all this and has this cap.

I need help. Anyone's thoughts, experience, knowledge? I'm in tears. I don't wan't to lose all this weight again, just to have it gained all back and more like I have my whole life. My body can't take it anymore, especially now that I have all these new comorbidties. Any work for Chase and has UHC that could inform me of the requirements? Or any help. I'm desperate.

Your responses would be so much appreciated.

Thanks

Comorbidities

[MK1986 78]

I would cut out the headache and go to Mexico. It costs about 5,000. I heard that Dr. Almanza is great!

[Kristina J. 581]

I would cut out the headache and go to Mexico. It costs about 5' date='000. I heard that Dr. Almanza is great![/quote']

It is definitely not for everyone, and I can completely respect and understand if it's just not something you'd be open to, BUT, MK has a point if it is something you'd consider, you should look into Mexico. There's a whole forum on here about people who have had wonderful success for not much more than what you're looking at paying out of pocket even WITH insurance. I know for me, it was my only option, since our insurance considers it a contract exclusion (ie: even if you will die tomorrow without it, we won't cover it) and my husband is too far advanced at his job to even consider a move.

If you're open to it, take a look around the Self-Pay/Mexico Forum, and ask some questions. You may be surprised at what you find out! I know for me, after asking around I decided that the overwhelming response was that Dr. Fernando Garcia was the best there is!

Best of luck. I know how frustrating insurance can be. I've had WLS with and without them. They definitely make it difficult to get the help you need to get healthy!

[PdxMan 4,292]

If you don't feel comfortable with MX, my surgeon charges $10,400 and is in Las Vegas (baby!) I would definately recommend him.

[Kristina J. 581]

$10,400 is really reasonable for self pay in the states!!! Plus, how do you beat Vegas?!? Lol I would probably show up a week before surgery

For reference, I probably should have mentioned, Dr. Garcia is $4700 which includes everything except airfare to San Diego.< /p>

[Jordy423 0]

Thanks for all the responses everyone. I will look into the doctor in Vegas and Mexico. Just hearing "Mexico" somehow scares me because I know this is a very serious surgery and can have complications if not done right in the hands of a great doctor. But I will definitely research all my options before I push any away. Thanks all. I never thought about finding a cheaper surgeon out of state.

[Jordy423 0]

PdxMan who is your surgeon in Vegas??

[PdxMan 4,292]

Thomas Umbach

Without going into it, it was worth the extra $5,000 to have it here in the states. Plus, I had a mini-vacation in Vegas (baby!). It was great. Got to walk around all the casinos indoor, air conditioned ... sat down and played a few hand of blackjack 5 hours after I was discharged.

View this page in a web browser to see all my stats in my signature.

Highly recommend Dr. Umbach. PM me if you want to know more.

[Kristina J. 581]

Yeah, it really is all about your comfort level. If it's not something you're comfortable with, then it's worth whatever the price difference!!

[Jordy423 0]

Thanks guys! I'm going to call Dr. Umbach's office in the morning for more info.

[iggychic 1,405]

Just a note from an employer. After having this surgery I am one of those evil employers who want to see a significant validation for this surgery, like the five year rule, and no surgeries for low BMI without comorbidities. From a financial view point, this surgery cost my company half a million dollars. I certainly don't want to encourage that kind of risk financially for any company, but more importantly, it nearly killed me. This surgery needs to be carefully considered before the step is taken. It's not for short term weight issues, nor low BMI nor lack of comorbidities. It's far to drastic for that. I know that sucks, but that's reality and if it keeps someone from going through what I did, I would feel nothing had been done wrong in having those restrictions.

[Fiddleman 4,376]

Just a suggestion, but are you near your open enrollment period? The reason I ask is because my insurance is also UHC, but I paid a little extra in my monthly premiums for the premium plus package. About 400 extra a month for my wife and I above what my employer will pay. UHC had no problem approving us under the premium plus. Is that an option?

[Kristina J. 581]

Just a note from an employer. After having this surgery I am one of those evil employers who want to see a significant validation for this surgery, like the five year rule, and no surgeries for low BMI without comorbidities. From a financial view point, this surgery cost my company half a million dollars. I certainly don't want to encourage that kind of risk financially for any company, but more importantly, it nearly killed me. This surgery needs to be carefully considered before the step is taken. It's not for short term weight issues, nor low BMI nor lack of comorbidities. It's far to drastic for that. I know that sucks, but that's reality and if it keeps someone from going through what I did, I would feel nothing had been done in having those restrictions.

I'm so sorry for all you went through!! It's so heartbreaking for anyone who thinks that WLS is their answer only to have their health put at such risk!! Sometimes we try so hard to do the right thing and it's really hard to know what that is. I really hope that since you've (clearly) survived that you are making the most of what you've been through. It's great that you're here sharing your story. I think we all need to be aware of the risks that we are opening ourselves up to. I'm not aware of what your complications were, but I do hope that you have healed and are enjoying some success from your traumatic mess of a journey!!

I think that anyone going into any kind of surgery, for anything, not just weight loss, needs to weigh the risks of that surgery (both short and long term) with the risks of their condition. Which in a sense is what insurance companies try to do by the numbers, though sometimes, they fail, on both sides of the coin. Someone who really shouldn't be approved, may be, while someone who really needs the help, may be denied. Such is the nature of the beast, if you will. lol

I know it can be frustrating dealing with insurance and I know as an employer it can be difficult dealing with the expense of surgeries that you can view as semi-elective or fully-elective that are very costly (WLS and otherwise). The insurance companies requirements exist to protect both us and them. I definitely understand that. For myself, with a 47 BMI and multiple comorbidties, I know, along with my primary care doctor and surgeon that this is the right choice for me, even though my insurance doesn't support it under ANY circumstances, but I do it knowing the risks and even having lived through some of them myself. I think we all need to be very aware of the risks and weigh those against our current and potential health!! No one thinks they'll be that 1% until they are!

It's definitely a valid point and something to think about Iggy... and I definitely don't think you're an "evil employer" at all!! I think you've seen the risks first hand and just want people to be darn sure they know what they're getting into and make sure really need it, especially if they're doing it on your dime. I would be lying if I said I didn't take pause at some of the lower BMI's I see on here jumping on the table to lose 50-75lbs. I love that you care and share your story!!! I think we should all be grateful!!

[amandalynn76 15]

Hey all' date='

I need your assistance! I'm new to this site. My aunt had her VSG last August and looks amazing. I attended a seminar 3 weeks ago that my aunts surgeon asked her to speak and share her experience. She and my doctor recommended this surgery and I was so hyped to learn of this procedure, turned in my insurance information at the seminar and enrolled into "the program"

Thispast Monday was my appointment to go over insurance, and she immediately told me my UHC Premium PPO has a lifetime max of 15,000 and I must have a 5 year history in order to qualify. My out of pocket would be 3200 which is do-able... however the surgery will cost well over 15,0000 and I do not have a 5 year history <img src='http://www.bariatricpal.com/public/style_emoticons/<#EMO_DIR#>/sad.png' class='bbc_emoticon' alt='' /> My weight has gone up and down, up and down over the last 10 years, and I've moved so much within the last 5 years I didn't have health insurance for awhile and no record of 5 year history. My BMI is 39.5 now after losing 10 lbs due to new Migraine medication, (before it was 40.3) with multiple comorbidities (hypertension, high cholesterol, PCOS, foot pain/arthritis, GERD and urinary incontinence which is all new to me that started 2 years ago.)

I'm at a loss. The insurance nurse told me I need to find other insurance. Do I really need to find another job to get this procedure done? I had an interview with JPMorgan Chase last week who I believe goes through UHC as well, but the nurse believed they worked better. I don't want to risk getting a new job making less money, just to find out I'm denied.

I called the number on the back of my insurance card to confirm if this was in fact true, and they said yes and would have a bariatric case nurse from UHC call me within 5-7 business days... but they will probably just confirm this awful news that my employer is requiring all this and has this cap.

I need help. Anyone's thoughts, experience, knowledge? I'm in tears. I don't wan't to lose all this weight again, just to have it gained all back and more like I have my whole life. My body can't take it anymore, especially now that I have all these new comorbidties. Any work for Chase and has UHC that could inform me of the requirements? Or any help. I'm desperate.

Your responses would be so much appreciated.

Thanks <img src='http://www.bariatricpal.com/public/style_emoticons/<#EMO_DIR#>/smile.png' class='bbc_emoticon' alt='' />

Comorbidities[/quote']

Hi,

My partner works for chase in illinois. Im just waiting for an approval from UHC. They require BMI of 40 and up or 35-39 with 2 co- morbitites and a 6 month supervised diet. As of the beginning of the year, the diet does not have to be consecutive as long as you have records of seeing a doc for weight loss in the past 2 years. A visit to the psych doc is also required. I have heard a lot of different stories from UHC, but this what my caseworker from UHC has told me. Chase has some great perks with its insurance. So far I have not paid a dime for any of my doctor visits. You can earn up to $1300 in a medical reimbursement account. I have a 1500 dollar deductible, so that money covers most of it. You are also eligible for another $1000 if you receive bariatric surgery from a center of excellence.

I started with a BMI of 42 weighing 239 lbs, 5'4"

Fell free to message me with any other questions.

Amanda