Insurance denied me :/

[gymbremom 27]

So upset. Got a denial phone call today. My bmi is 41. Said since I was on a diet plan in the last 2 years and lost weight that I should be able to do it on my own!!?! I have been morbidly obese for 15 years. Makes me sick :/

[Inner Surfer Girl 12,015]

I am so sorry to hear this. After being around these boards for a long time I would suggest that you appeal. You should be able to get your PCP or surgeon to help with the process.

Don't give up.

[BLERDgirl 6,417]

I agree. I realize this is disheartening to hear, but you would be surprised the people who appeal and get approved. Please do not give up until you have exhausted ALL appeal options.

[ellieschad 6]

So upset. Got a denial phone call today. My bmi is 41. Said since I was on a diet plan in the last 2 years and lost weight that I should be able to do it on my own!!?! I have been morbidly obese for 15 years. Makes me sick :/

Do you have medical issues because of your weight? if you do, maybe your doctors office can help with getting the insurance to step up.

My insurance denied me because My BMI was below their requirement, because I was adopted and do not have biological history, and do not currently have weight related health issues. I went with the self pay because I do not want to get to the place insurance wants me to be before they will pay.

[Edavidson 84]

Gymbremom: Don't give up, my insurance turned me down too. Have your PCP send a letter stating

that your diet plan has failed. The fact that you have been on a diet for two years and have not

lost a substantial amount of weight is what usually gets you approved. Please keep trying...

[gymbremom 27]

Thanks so much for everyone's replies. This evening has definitely been a bummer. I am going to call my pcp tomorrow and see if he will write a letter or something. He has seen me for over 20 years and has known my track record also on diet failures

[Edavidson 84]

You will be so happy you called your PCP for a letter of recommendation regarding your weight loss

surgery. Never give up.

[gymbremom 27]

I hope so. I am so bummed right about now :/

[tnkrrbl 53]

Mexico?

[Chanel22 19]

My insurance denied me twice.. The third time I was approved.. You can fight it.

[gymbremom 27]

Chanel, what was the reason they were denying you and how long did all of the appeals take?

[marybowlus 17]

Who is your insurance provider?

[WontonAnimalChIndo 18]

Sucks. Fear of this keeps me up at night. I just started the insurance approval. I think I've done all my homework so hopefully all my ducks are in a row

[gymbremom 27]

I honestly thought I met all the criteria so I was very shocked to get the denial phone call. I have united healthcare.

[Edavidson 84]

Hi, I don't know if this will help but I pulled this information on United Health Care coverage.

See what you think, I thought it was very interesting. If your state requires them to offer

weight loss surgery, even though they don't normally cover it. By law they have to comply. You

may be in luck. Most people don't know this and they get away with it. See below

United Healthcare’s Criteria For Weight Loss Surgery Coverage

In Am I Covered by OC Staff/October 19, 2013/

While many United Healthcare Summary Plan Descriptions and Certificates of Coverage explicitly exclude coverage for weight loss surgery, many plans do cover surgery. In fact, some states require insurance companies to cover weight loss surgery, so even if your policy excludes it, if your state mandates coverage you may be in luck!

United Healthcare’s pre-approval criteria for surgery

The following criteria must be met to receive coverage:

1.Class III Obesity (Body Mass Index greater than 40)

2.Class II Obesity (Body Mass Index greater than 35) with one or more of the following co-morbidities: 1.Type 2 diabetes

2.Cardiovascular disease (such as hypertension, stroke, angina)

3.Severe sleep apnea or other life threatening cardiopulmonary conditions

For fully insured policies in Maryland:

1.A Body Mass Index above 40 without comorbidities, or

2.A Body Mass Index of 35 or greater with comorbidities including: 1.Hypertension

2.Sleep Apnea

3.Diabetes

4.Cardiopulmonary condition

5.Any other life threatening medical condition that is weight-induced.

3.You must show proof that you’ve followed diets but were unsuccessful losing weight long term. These can include Jenny Craig, Weight Watchers, etc. •In the last two years you must have participated in: •One structured diet program for 6 consecutive months; or

•Two structured diet programs for 3 consecutive months.

4.18 years of age or older

Which weight loss surgeries are covered by United Healthcare?

1.Gastric bypass

2.Lap Adjustable Gastric Bands (i.e. Lap Band or Realize Band Surgery)

3.Gastric Sleeve Procedure (also known as laparoscopic sleeve gastrectomy)

4.Vertical banded gastroplasty

5.Biliopancreatic bypass (Scopinaro procedure)

6.Duodenal switch

The following procedures are covered in adolescents:

1.Gastric bypass

2.Lap gastric bands

3.Gastric sleeve

Are lap gastric band fills covered?

Lap gastric band fills are covered for those patients that undergo Lap Band or Realize Band surgery.

What procedures are not covered?

1.Mini-gastric bypass

2.ROSE, StomaphyX, TOGA

3.Gastric electrical stimulation

Is a second weight loss surgery covered if lap band doesn’t work?

Yes. Assuming the same conditions to qualify for the original procedure are still met.

What if there is a problem? What if I don’t lose weight?

If you have a complication related to the surgery United Healthcare will cover any related procedures or hospital stay. If you do not lose weight and you still meet the original criteria for coverage a second procedure will be covered.

Does United Healthcare require a Center of Excellence?

As far as we can tell, no. But, by choosing an in-network surgeon, you will save on your out-of-pocket expenses.

United Healthcare’s contact information

United’s contact information is arranged by state. Click here and select your state.

United Healthcare’s weight loss surgery full coverage statement

United Healthcare’s full statement of coverage can be found here.