Called UHC, little confusing????

[Maggie225 0]

I called my insurance today (United Healthcare) and Lap Band is covered at 90% which is awesome but then I was told I have no Bariatric Resource coverage, which I guess is just a service some employers pay extra for, it covers having a team find you a doctor and I guess they work with you and help you understand the procedure, aftercare, etc. I'm guessing this is no big deal because I have already found a surgeon close to me (1 1/2 hrs drive away) and I'm sure he will give me the info on the surgery, etc right? And this surgeon is in my network so there shouldn't be any problems.

The question I do have is; when I asked what the guidelines were for the lap band all the lady could give me was the "generic" version off something she was reading, she stated you must be obese and have health problems relating to the obesity, she did not give me any BMI numbers or anything???? When I visit my PCP and he sends me to the surgeon will they be able to get all the guidelines? I really wanted something in writing to take to my Dr. so he could see the guidelines.

Well I guess I'll just go and if I get denied I'll appeal it.:laugh:

[susan1961 0]

General rule is BMI 40 or greater, or BMI 35-40 with comorbidities (ie significant weight-related health issues like hypertension or diabetes, but there's a long list). There is evidence of benefit with BMI < 35 but insurance won't pay for it.

Almost all surgeons will require a psychological evaluation and a meetiing or meetings with a nutritionist. Those cost me $300 each (one psych eval, and 4 meetings with the nutritionist, 1 pre-op and 3 after).

[Jodi_620 37]

Your doctor should have an insurance coordinator that can deal with the specifics of insurance coverage and getting pre-approved.

Your doctor should also have staff to teach about the procedure, pre-op and post-op care, diet and all that stuff. I would be surprised if they didn't but IF they don't, you should find one that does.

[ckelly37 1]

If u have no baruatric coverage under ur insurance that means they wont pay for the procedure?? I had aetna and it was a $200 copay for bariatric surgery but they told me it was excluded from my policy so i switched insurance companies because i really wanted this done and i didnt want to become self pay...make sure ur insurance will pay for the procedure...ask ur HR if bariatric surgery is included or excluded...good luck

[Maggie225 0]

The actual lap band surgery IS covered but the extra services which they call "bariatric resources" is not covered. I asked the UHC rep if this really mattered and she said probably all the things I would need could be done through the surgeon, as Jodi stated above. All the bariatric resource people do is find you a surgeon and cover other stuff with you, so it's no big deal that my husbands employer doesn't carry this extra service. I'm not sure if the extra service helps or hinders your approval, but I'm just glad to know that the procedure is covered and I had 2 different UHC reps plus the bariatric resource nurse that I talked to confirm that the lap band was covered under procedure code 43770 (in case anyone wants to know the code:cool2:) through my insurance.

Now I guess I need to take the next step, I do have a BMI of 35.1 and I am diabetic, I have PCOS and I have knee and back pain so hopefully that will be enough to get it approved. *keeping my fingers crossed*

I'll keep you all updated as to how it goes

[Aggie98 0]

Good luck Maggie! I also have UHC and my doctor should be submitting to my insurance today or tomorrow. Hopefully I will be approved!

[JayTee562 1]

Maggie

There are several post on her from people who had really good luck with UHC. I only talked to my original insurance company (Atena) once to get some info for the Bariatric Center. My PCP referred me to a surgeon required by Aetna his office assigned me a coordinator and she has made all the contact with both Aetna and my new (1/1/09) insurance company (UHC) and has contacted every week or every 2 weeks to remind me of what I still needed to do. It's kind of scary to hear everything other people have had to do for themselves I hope I don't get a big surprise at the end that I needed to do more.

If you find a good group they will have people to help you through the process and know exactly what to tell the insurance company. When we switched to UHC my requirements got easier... 2 years of records 6 office visits to PCP noting your weight and the issues caused by it..they didn't have to be in a row this moved me up in my process by 2 months.

Look at the local group for where you are from and there should be post from people wiht their experiences at different Dr's. Good Luck

[gingerbug 3]

Ihad an easy time with UHC. BMI of 40 or higher with no comorbidities, 35 up to 40 needed two. 5 years of weights and I just called my GYN and asked them to compile a list of weights for the last 5 years and have the doc sign off on it. It showed my weight up and down all over the place. I brought that to my docs office and they sent it all in for me.

[Huse 0]

Good luck Maggie! I also have UHC and my doctor should be submitting to my insurance today or tomorrow. Hopefully I will be approved!

Why did you have to have all those additional tests done? I have UHC PPO Plus and they told me that since my BMI was 41.8 that was all I needed to have my consultation and surgery performed. I do have other medical conditons cause from being overweight, but UHC said that the only pre req was that my BMI was over 40. Do you perhaps have an HMO and need the other studies done to get approval? UHC said I did not even need to get a referral from my PCP as that was not required through my policy. Please explain because I am very new to all of this. Thanks:rolleyes:

[Aggie98 0]

Why did you have to have all those additional tests done? I have UHC PPO Plus and they told me that since my BMI was 41.8 that was all I needed to have my consultation and surgery performed. I do have other medical conditons cause from being overweight, but UHC said that the only pre req was that my BMI was over 40. Do you perhaps have an HMO and need the other studies done to get approval? UHC said I did not even need to get a referral from my PCP as that was not required through my policy. Please explain because I am very new to all of this. Thanks:rolleyes:

Absolutely. The other tests that I had done were tests that were required by my surgeon, not UHC. The EKG/Stress Test and sleep Study were done to ensure I was I was medically fit for surgery... additionally the sleep study was done to possibly diagnose sleep apnea which can be listed as a co-morbidity and help me get approved for surgery (I ended up not having sleep apnea.)

The nutritionist and psych eval were done to make sure that I was able to make the changes necessary to be successful with the Lap-Band.

Hope that helps!

[laurie39 0]

I have uhc as well. You can request a copy of your insurance, but when you talk to your insurance rep your specifically asking about a bariatric rider or obesity surgery. You can get online at myuhc.com and they can email the requirements to you. The bariatric center I chose is less than 15 minutes, they require bmi over 40 or 35 with 2 comorbidities. There is a program fee that is not submitted to insurance that includes 13 weeks of a medically supervised diet, lose 10% of your excess weight, see their dietician, physical therapist, and a psychologist. The program fees are eligible for the health savings account if you have one.

[Huse 0]

What surgeon did you go to, if you don't mind me asking? I already had those tests done 6 years ago when I was thinking about doing the gastric by-pass and I really don't want to do all of them again. It was very time consuming, and at this point I am just ready to get started.

[laurie39 0]

Things change in 6 years. The surgeon will want up to date information and test results. I was a little disillusioned by the 13 week diet...can't they see I'm fat, just let me have the surgery, c'mon!! But they want to know that you are committed to make a life change. The band is not a cure, its a piece of silicone.

Do we want a healthier life? Do you want to fit on the roller coaster with your kids? I kinda do!

[Huse 0]

Do all surgeons require the 13 week diet, stress test, sleep study, psychologist testing, etc. or are some doctors easier about getting this procedure. I have had recent blood work and everything is fine with my liver, thyroid, blood sugers, etc. Also I have been seen by a cardiologist and received a clean bill of health regarding my heart in May. Just trying to figure out what all will be required.

[Jodi_620 37]

If it was recent (last couple months) then you may be able to have those results forwarded to your surgeon but if it was six years ago then you will likely need to have these tests done again.

I was not required to have a sleep study, 13 week diet or stress test (in my experience, these things depend on insurance requirments) The psych evaluation is important to make sure you are prepared and educated on this process as is the nutrion classes. As already mentioned, the liver and EKG tests are necessary to make sure you are healthy enough for surgery and the other tests are necessary in order to make sure that you do not have any underlying conditions that will hinder weight loss...those need to be treated and under control first.