UHC- Denial-Now what!!

[KEKE77 1]

Hello I am KEKE 42 and about 8 mths ago I started the process for getting a gastric sleeve. I called my insurance UHC which at the time told me that normally this isn't covered but if I meet certain criteria I could be. BMI over 40(check), high blood pressure, sleep apnea, tried every diet , and pill supplements prescribed and over the counter( check).

So I had to do 6 months nutrition visits- which I completed without a hitch 2 months ago. Now time for the preapproval call- before the office could get a word out they just flat out said not covered.

I was baffled at this because this is not what I was told at the beginning otherwise I would have figured something else out and not have gone through this whole process to be just told no. There was no official denial so I can not appeal , they just said not covered.

Apparently this has happened to many other members, by being told yes at the beginning to be told differently at the end. Not only am I a member of UHC I also work for UHC. So now it has become apparent that the reason for this "not covered" is because UHC doesn't cover the surgery for employees. I was like what!! That is the stupidest thing ever.

So now what do I do? Ive considered looking for another job, I was actively looking, but my luck as soon as I leave then it would be covered for employees. I don't qualify for Medicaid as a secondary.

I need assistance on getting my surgery approved or guidance to a secondary insurance company that will cover WLS in CT, Loans are not an option nor is paying out of pocket.

I know I need to wait for open enrollment but I just need to know the best insurance company to apply for when October comes around.

Thank you all for any input

[Diana_in_Philly 1,426]

Step one - review your policy - look at the documents - either they were given to you in paper or are avaialble on line - that will outline what is covered and what is not. Since you did not get them to commit in writing in the first instance, you can't rely on that. If the policy website/paper copy says covered demand a denial of coverage letter so you can appeal. Talk to the insurance coordinator at your surgeon's office - they have done this more than once before and maybe she/he can help you. If you are coverage is provided as an employee, you may be covered by a Federal Statute called ERISA which gives you specific rights regarding appeals of denials and the requirement that they put the denial in writing. Secondary insurance will likely not cover it at this point. Changing jobs will only help if you get a job with a company whose insurer covers bariatrics and many don't. Call your human resources department and ask them for copies of the paperwork for your plan.

[KEKE77 1]

Thank you Diana,

If I was not an employee of UHC I would be covered, they do not cover as an employee currently, they stated last year that they were in the works with adding it, they said it may be added this year but its just a waiting game. And yes changing jobs would actually help because a lot of companies in CT offer it - I am a coder so I have lots of options- it is just the fact my company is based in TN I am a remote coder so TN isn't currently a mandated state for offering bariatric surgery, Neither is CT but majority of the companies that I have considered do offer it. I just have to weigh out the fact of being remote for 5 years to going back into an office setting.