United Health Care- Need only doctor recommendation?

[HotMama24 0]

My husband called UHC for me today to get information about them covering my WLS. The representive told him, after reviewing our plan, that they just needed a doctors letter saying that it was medically necessary.

Is this common? This just seems TOO easy. We didn't know if we would be able to have it covered because my BMI is 35.4 and my only co-morbidities are PCOS and infertility.

Any thoughts?

[Claytaco 0]

Typically, UHC requires five years of medical records that show that your BMI has not gone below 35. PCOS certainly counts as a co-morbidity. The majority of UHC plans also require six months of diet and exercise under a physician’s supervision.

I would call back or better yet have a professional call and verify the requirements with your plan. If your plan has liberal policies on authoritarian, jump on it.

FYI: many of our patients with infertility often get pregnant in their first year. I thought you would find that reassuring to know that you are on the right path!

I wish you well!

--Clay

WLIAZ Employee

My husband called UHC for me today to get information about them covering my WLS. The representive told him, after reviewing our plan, that they just needed a doctors letter saying that it was medically necessary.

Is this common? This just seems TOO easy. We didn't know if we would be able to have it covered because my BMI is 35.4 and my only co-morbidities are PCOS and infertility.

Any thoughts?

[HotMama24 0]

Thanks for your response. It is nice to have an answer from someone who works on the other side of this. So would you recommend for me to call a surgeon and have their office call the insurance company? Is that the best way to go about it? Thanks!

[Claytaco 0]

Yes, if your surgeon's office can call for you that would be best.

They will ask: Does this patient have the benefit for bariatric surgery related to morbid obesity?

The procedure code for the band is 43770.

They will then find out what the specific requirements are such as if you need diet and exercise and how many years of records (where your BMI was at least a 35) you need.

Again, UHC criteria are highly standardized.

--Clay

WLIAZ Employee

Thanks for your response. It is nice to have an answer from someone who works on the other side of this. So would you recommend for me to call a surgeon and have their office call the insurance company? Is that the best way to go about it? Thanks!

[HotMama24 0]

Ok, isn't morbid obesity 40 and above? My BMI is only 35.4. It says in my plan that for morbid obesity it is covered. I am a little unsure because my BMI is only over 35, not 40.

[Claytaco 0]

These are the qualifications for lap-band surgery with UHC as I know them…..

A benefit for bariatric surgery related to morbid obesity.

BMI of 35-39.9 with two or more health problems associated with patient’s weight.

Or

BMI of 40-above without health problems associated with patient’s weight.

5 years of medical records (one medical encounter each year showing that your BMI is within range above). Some out of state or unusual plans can require fewer records.

Diet and exercise for six months under the supervision of your doctor or bariatric clinic.

Everything else you need, you get at your doctor’s office.

--Clay

WLIAZ Employee

Ok, isn't morbid obesity 40 and above? My BMI is only 35.4. It says in my plan that for morbid obesity it is covered.

[HotMama24 0]

Thanks so much, Clay.

I will be contacting a surgeon soon...as soon as I choose one :biggrin: Thanks for your help!!

[MistyD65 1]

I have United Health Care though a third party administrator, UMR (formerly Midwest Security Administrators). I was pleasantly surprised when I was almost immediately approved for surgery after meeting with my surgeon for the first time. In late 2007 I had looked into lap band with another surgeon. I had UHC then also, but through a different administrator. I was told at that time that my insurance required the 6-month doctor supervised diet and a psych consult, so I put thoughts of surgery on the back burner.

Maybe my husband's company made some changes in what they wanted their insurance to cover. But whatever the reason for the change, I was very grateful. I also have to give all the credit to my surgeon's office for getting me approved. They did all the dealings with the insurance company.

[Aggie98 0]

I have UHC Choice Plus, and all that is required of me is 40+ BMI or 35-39 BMI with 2 co-morbidities, and 5 year weight history from my doctor.

I hope to have everything submitted to UHC this coming week. I have heard that they are one of the easier insurances to get approved, and they are usually pretty quick in making a decision. We'll see!

Good luck!