Success in Peer-to-Peer with UHC?

casenior · August 16, 2016

So my company's policy only has 2 requirements for obesity surgery: 1. Minimum of 40bmi for 5 years & 2. Be a minimum of 21 years old

I had lapband surgery in 2008 and lost 60 lbs before it eroded in 2011. I had to have it removed and by 2013 was back up to my pre-op weight of 255. At the time I was with another employer and weight loss surgery was an exclusion so no revision surgery for me.

Last week UHC denied my request for the sleeve because I don't have 5 years of a 40 bmi.. Despite my doctors notes that I had another procedure in place in the beginning which was why I don't have 5 years.

My surgeon's care coordinator told me yesterday that they have scheduled the peer-to-peer for next Tuesday. She said 9/10 times the "medical director" that reviews the requests is a primary care physician and they don't fully review everything submitted, they just look to see if you satisfy the eligibility requirements. So she is confident my surgeon can get them to overturn the decision.

If this type of situation happened for you with United Healthcare (initial denial), what happened for you?

Thank you!

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WLSResources/ClothingExch · August 16, 2016

peer-to-peer for next Tuesday. She said 9/10 times the "medical director" that reviews the requests is a primary care physician and they don't fully review everything submitted, they just look to see if you satisfy the eligibility requirements. So she is confident my surgeon can get them to overturn the decision.

I don't have your experience, but am stopping to throw out a couple of thoughts.

Maybe I'm missing something here. If the reviewer looks at the paperwork only to see if you meet the eligibility requirements (minimum 40 BMI for 5 yrs and 21+, as you report), it seems that you'll be rejected again. Wouldn't that mean it's likely that the initial denial will stand?

. I had to have it removed and by 2013 was back up to my pre-op weight of 255.

Last week UHC denied my request for the sleeve because I don't have 5 years of a 40 bmi.. Despite my doctors notes that I had another procedure in place in the beginning which was why I don't have 5 years.

It certainly won't hurt your peer-to-peer procedure if you supply letters in support of sleeve surgery from any and every doctor you can. These letters aren't about explaining why you don't have the required five years, but rather to state all the medical reasons you need to lose gobs of weight, all sorts of health and physical problems that are dangerous and can be solved by weight loss. If you do have doctors who can whip out brief letters, you need to move fast so that your insurance coordinator can get them to the peer review people. It can't hurt your case.

If the process fails, you may choose to go to the next stage of appeal, whatever it is. I don't have personal knowledge of them, but there is a law firm that works on these things. If you'd want to consult, the head's is Walter Lindstrom.

If worse runs to worst, would you be covered if you wait until you have 5 years of 40BMI? Would you be covered despite the earlier surgery? Just tossing out questions in case they haven't occurred to you.

Good luck.

casenior · August 16, 2016

peer-to-peer for next Tuesday. She said 9/10 times the "medical director" that reviews the requests is a primary care physician and they don't fully review everything submitted, they just look to see if you satisfy the eligibility requirements. So she is confident my surgeon can get them to overturn the decision.

I don't have your experience, but am stopping to throw out a couple of thoughts.
Maybe I'm missing something here. If the reviewer looks at the paperwork only to see if you meet the eligibility requirements (minimum 40 BMI for 5 yrs and 21+, as you report), it seems that you'll be rejected again. Wouldn't that mean it's likely that the initial denial will stand?

. I had to have it removed and by 2013 was back up to my pre-op weight of 255.

Last week UHC denied my request for the sleeve because I don't have 5 years of a 40 bmi.. Despite my doctors notes that I had another procedure in place in the beginning which was why I don't have 5 years.

It certainly won't hurt your peer-to-peer procedure if you supply letters in support of sleeve surgery from any and every doctor you can. These letters aren't about explaining why you don't have the required five years, but rather to state all the medical reasons you need to lose gobs of weight, all sorts of health and physical problems that are dangerous and can be solved by weight loss. If you do have doctors who can whip out brief letters, you need to move fast so that your insurance coordinator can get them to the peer review people. It can't hurt your case.

If the process fails, you may choose to go to the next stage of appeal, whatever it is. I don't have personal knowledge of them, but there is a law firm that works on these things. If you'd want to consult, the head's is Walter Lindstrom.

If worse runs to worst, would you be covered if you wait until you have 5 years of 40BMI? Would you be covered despite the earlier surgery? Just tossing out questions in case they haven't occurred to you.

Good luck.

Yes I'd be covered but I have other health issues right now that I need the procedure for.. And I work in oil and gas and chances are we will see more layoffs.

My doctor should be able to justify that this is a revision of the failed procedure UHC covered me for before. That I have health issues now that would greatly be reversed through the weight loss. If I went in today to have my lapband removed, UHC would cover a revision. Hands down, no questions asked.

My surgeon has had success in overturning their decision before and the care coordination rep I spoke with at UHC said that she sees the initial denials get overturned all the time especially for someone in my position.

The peer to peer is a chance for my surgeon to sit down with the UHC medical director and clearly state the facts and fight for approval. If that fails the next step is appeals and that's where I would get any and all supporting documentation from my other physicians.

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WLSResources/ClothingExch · August 16, 2016

Duh, I missed that part -- of course "peer-to-peer" means someone on "your side" will be there to speak up. At least I indicated that the territory is unfamiliar to me. It sounds as though you're in as good shape as can be expected for now. I hope you get what you want on Tuesday. Please post again when you get the results. If you click the little blue "Mention" under my screen name once you've clicked into the new-message pane, I'll get a notice about your post. I'd like to know.