UPMC conflicting information.

[Theresa23 3]

I am going through the approval process with my surgeons office, and I have a question about my insurance. I have UPMC for you in Lehigh County, PA. I am getting conflicting information from call center reps about the requirements. Specifically the medically supervised diet, I have been told 3 months, 6 months and no diet is required. So, I found the Policy and Procedure manual on UPMC's website for my policy. It states that with a bmi over 40 (mine is 43) I need to meet one of the following requirements either have a co-morbidity, or have 6 months of doctor supervised weight loss. I have moderate to severe sleep apnea, which is a listed co-morbidity. So in my mind I meet the qualifications.

However when I called back with the policy and procedure manual I was told that the 6 month weight loss program was a requirement of my surgeons group. This is not the case, I spoke to the nurse at my surgeons office and was told that they don't set those requirements.

I just had my 3 month weigh-in and we decided to submit for instance yesterday.

If I am denied will I be able to speak to UPMC's medical department that makes the decision? How long should I expect to wait for a decision? Any other advice or information would be appreciated! Thanks

[Theresa23 3]

Just in case anyone was wondering the outcome was I was APPROVED! My doctors office even thought I was going to be denied, and be forced to do another 3 months of weigh ins, but I was right about the policy and procedure manual.

[Daisee68 2,493]

That is great news!! Congrats!!

[ecburger 0]

Congrats on your approval! I have the same insurance located in Lehigh Valley... Wondering if you would be able to direct me to the area on the website that you found that info? I'm in the very beginning stages of the wls journey and want to be prepared when I go for my first appointment. Surgeons office seems to think that there is a 6month med supervised diet requirement, but when I spoke with UPMC for you directly, they said there is no set requirement... I'd love to follow a 3 month timeline like you did! Any info you can give me would be appreciated! Thanks!

[Theresa23 3]

Congratulations ecburger on deciding to have wls, it was the best decision of my life no regrets! Here is the link, if it doesn't work let me know I can scan and email the document to you. If you need any help understanding the insurance language let me know also willing to help.

https://www.upmchealthplan.com/docs/providers/PandP/MP.040.pdf

[ecburger 0]

Thank you so much Theresa23! This will be such a help to have with me when I have my first meeting with the surgeon's office.

I'm excited to start this process, so it's great to hear from someone that has gone through it before me!