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Hello all,

I am in the middle of the appeals process with my H M O. I have United Healthcare. Is there anyone out there who was approved and had surgery through their UHC H M O? If so, how did you go about it? Any info would be appreciated. Requirements, appeals etc.

Thanks!

Hello all,

I am in the middle of the appeals process with my H M O. I have United Healthcare. Is there anyone out there who was approved and had surgery through their UHC H M O? If so, how did you go about it? Any info would be appreciated. Requirements, appeals etc.

Thanks!

also, what type of policy did you have? PPO or H M O?

that sounds about right. The minute you fall below 40 you have to have comorbs to qualify. I have heard of some people buying ankle weights and other inconspicuous weights for the monthly weigh ins. Some people wear the ankle weights with boot flare jeans and have a large lunch before being weighed in. I know that might sound like cheating but consider the alternative. Just food for thought. ;)Good luck!

Cheri

could I please get a copy to? I just got denied for the surgery cstahl1973@msn.com

Thanks!

So here's a question. How many years to you have to show that your BMI was 40 or over? I dipped below to 38-39 a couple of times while dieting over the past 4 years. But I always regained and went back to my original BMI of 41.

Has anyone heard of UHC *** requiring a BMI of 35 or over with one comorbidity for surgery? I was denied for the surgery stating that I need to have one comorbidity to qualify.

However, when they first denied me for my consultation they indicated that I had to have a BMI of 40 OR a BMI of 35-39 with a qualifying comorbidity. That was the letter from the medical group. When I appealed the consultation denial to the insurance company I received a letter from UHC stating the same thing BMI of 40 OR a BMI of 35-39 with a qualifying comorbidity.

Now all of a sudden the game has changed? They clearly left out the part of the BMI being 40 or over on my most recent denial for the actual surgery. I have 2 documents from them on their own letterhead stating that a BMI of 40 would qualify if medically necessary. I guess that's what I will have to go after them with for my appeal to try and get the surgery.

UHC has my appeal as of right now so I will probably have to wait for 30 days until I know something. Right now I am finishing up the 3 required visits with the NUT and I did meet with their weight doctor as well. He wants to put me on a Medifast program but my NUT is absolutely against it. She is going to document her reasons why going on Medifast again will not work for me. So at least I have her in my corner.

So now I sit and wait again.... Does anybody out there have UHC West (formerly Pacificare ***) with Sharp Community? What did you have to do to get approved? My surgeon wrote up the surgery request indicating that I was morbidly obese and that he was recommending that I have surgery. My PCP also indicated that it was medically necessary. I don't know what else to do!

Help!

Thanks,

Cheri

Thank you for the words of encouragement! I just faxed over my 21 page appeal letter. I am going to blind them with paperwork! Actually the appeal was only 3 pages and the rest was supporting documentation, from receipts, to gym membership, to the 2 year weigh ins I had with the medically supervised weight program. I also threw in the NIH guidelines and the guidelines they specified to me when they first denied my consult.

I think it is sad how they play with peoples emotions. I went to see the medical groups weight doctor and my BP was 142/80! I have never been that high. In fact when I first started this process my BP was 107/69! I can very easily see how people develop problems during this process. All I can think is I am this close to being approved if they have to keep changing their requirements to deny me. So I will keep the pressure on!

OH! Did I mention that I met with the NUT and weight doctor on the same day? When I met with the weight doctor he wanted me to join Medifast. I told my NUT and she is dead set against it. She said she is going to document her opinion as to why she disagrees. So now what do I do!? I don't want the insurance to think I am not being compliant so I put that information in my appeal letter. I think a registered NUT would know more about nutrition that a PA...no offense to the PA but the NUT told me they get kick backs and that's why the push the Medifast plan.

I read your other post and I am in the same boat. I am right at 40 BMI. So I have stopped exercising because I cannot afford to lose a single pound right now. I need this approved!

Did your husband have to do a 6 month diet? Or just weigh in?

My husband is 6'3 and 300lbs with high blood pressure and high triglycerides so I am wondering how hard it will be for him to get approved? I am thinking not as hard as it's been for me since I did not have a qualifying comorb.

I will keep you posted. I hope to hear something soon because I want to get this weight off! :funscale:

Has anyone heard of UHC *** requiring a BMI of 35 or over with one comorbidity for surgery? I was denied for the surgery stating that I need to have one comorbidity to qualify.

However, when they first denied me for my consultation they indicated that I had to have a BMI of 40 OR a BMI of 35-39 with a qualifying comorbidity. That was the letter from the medical group. When I appealed the consultation denial to the insurance company I received a letter from UCH stating the same thing BMI of 40 OR a BMI of 35-39 with a qualifying comorbidity.

Now all of a sudden the game has changed? They clearly left out the part of the BMI being 40 or over on my most recent denial for the actual surgery. I have 2 documents from them on their own letterhead stating that a BMI of 40 would qualify if medically necessary. I guess that's what I will have to go after them with if my appeal for the surgery does not get approved again.

UHC has my appeal as of right now so I will probably have to wait for 30 days until I know something. Right now I am finishing up the 3 required visits with the NUT and I did meet with their weight doctor as well. He wants to put me on a Medifast program but my NUT is absolutely against it. She is going to document her reasons why going on Medifast again will not work for me. So at least I have her in my corner.

So now I sit and wait again....

As of right now I am not sure what to think. I had heard that it could be any detailed documentation in the last couple of years. I actually went to a doctors weight clinic and had a physical, B12 injections and phentermine for 2 years. So they have 2 years of weigh ins for about 2 to 3 visits a week. I was lucky to have all of that documented for so long. I went from March 2008 to March 2010 because I could not afford it anymore. I know for certain that those medical records were the reason I was able to even have the consult with the surgeon. At first I was denied because they wanted me to at least show "motivated" attempts at weight loss even though I had a BMI of 40. When my primary doctor sent those records in I immediately got approved for the consult. I am going to meet with their weight loss program department tomorrow. I am going to give him a copy of all of my records and receipts from all the diets I have tried. I seriously do not know what he can do for me. The NUT I am seeing is having me read a book called "Intuitive Eating" it's a great read and I recommend it but it does not agree with the diet mentality. So it's a big game and song and dance.

Right now I am battling with the medical group to get the surgery approved. They keep changing their tune. They are now saying I have to have a BMI of 35 with one comorbidity to be approved for surgery. According to UHC (the insurance) they follow the NIH guidelines for bariatric surgery. Based on the appeal letter I received directly from UHC (not the medical group) they clearly indicate that you can have a BMI of 40 with no comorbidities to have the surgery or 35-39 with certain specific comorbidities.

I used to work with medical groups so I kind of have an inside on how they operate. When you have an *** you choose a PCP and a medical group who are supposed to be in charge of all of your healthcare needs. The medical group receives their money from the insurance company for your care. That is why the medical group is fighting so hard to deny the surgery. They are the ones who actually have to fork over the money because in all actuality they have already been paid for my care by the insurance company. Basically the less your doctor has to see you the more money the medical group can hold on to.

It's a sick game but in the end like most things it's about profit. I will let you know if I find out anything about the diet requirements or if what I submitted works.

I have heard that if you have already been on a medically supervised weight loss plan for more than 6 months, that those records are ok to submit to satisfy the 6 month supervised diet criteria. Is this true? Does anybody have any input on this?

I have heard that if you have already been on a medically supervised weight loss plan for more than 6 months, that those records are ok to submit to satisfy the 6 month supervised diet criteria. Is this true? Does anybody have any input on this?

Ok so the drama begins...again. I just called the medical group this morning and they denied me for surgery. They are stating that I do not meet the obesity requirements and that I have to have one comorbidity to qualify with a BMI of 35-39.9, that I have to consult with a registered dietician and enroll in their weight management program. Almost sounds like a standard denial letter that they send out no matter what. I called the surgeon's office and am waiting for a call back from the nurse. They have all of the records from all of the plans that I have already tried. Maybe they did not send them in with the request?

I have written an appeal letter. First off, I have a BMI of 40 and per the policy requirements no comorbidity is needed. Second, I have already had the consult with the dietician who agrees that I would be a good candidate for bariatric surgery. Third, I went to a medically supervised weight clinic for two years, belonged to a gym for 5 years and most recently tried the HCG diet.

Along with the letter I am submitting all of these records directly to the insurance company. I did call to make an appt with their weight clinic. I will jump through as many hoops as they require. I can't give up on this and I will not go away without a fight!

I am feeling so discouraged right now though. I know it's the practice of the insurance company to deny everything. But still I am hopeful that I will win. Any words of encouragement or wisdom would be greatly appreciated.

Thanks,

Cheri

Ok so the drama begins...again. I just called the medical group this morning and they denied me for surgery. They are stating that I do not meet the obesity requirements and that I have to have one comorbidity to qualify with a BMI of 35-39.9, that I have to consult with a registered dietician and enroll in their weight management program. Almost sounds like a standard denial letter that they send out no matter what. I called the surgeon's office and am waiting for a call back from the nurse. They have all of the records from all of the plans that I have already tried. Maybe they did not send them in with the request?

I have written an appeal letter. First off, I have a BMI of 40 and per the policy requirements no comorbidity is needed. Second, I have already had the consult with the dietician who agrees that I would be a good candidate for bariatric surgery. Third, I went to a medically supervised weight clinic for two years, belonged to a gym for 5 years and most recently tried the HCG diet.

Along with the letter I am submitting all of these records directly to the insurance company. I did call to make an appt with their weight clinic. I will jump through as many hoops as they require. I can't give up on this and I will not go away without a fight!

I am feeling so discouraged right now though. I know it's the practice of the insurance company to deny everything. But still I am hopeful that I will win. Any words of encouragement or wisdom would be greatly appreciated.

Thanks,

Cheri

Thank you for the information. I am happy that I have decided to request the sleeve. I should hopefully know by next week if I am approved for surgery.

I actually started my weight loss journey in 2005. Since then I have lost about 40lbs on my own but I have hit a wall and have not been able to lose anything for the past couple of years. I made a commitment to lose weight and be healthier. I take supplements and I do exercise and even with all of that I could not lose another pound. It has been very discouraging to say the least. I still could not control my portions. I learned that you can still overeat even if you are eating healthy.

Then there was a ray of sunshine when I started to research the band a couple of years ago. I am glad I waited to pursue WLS because now the sleeve is open as an option for me. The thought of having a foreign body inside of me and getting poked to fill or unfill was not very appealing. I was also afraid of slippage and having things get stuck. I want something permanent. Something I can learn to use as a permanent tool to get on with a healthier life. If all goes well with my surgery my husband will be having it too. Which I think will be great because then we will both be committed to a healthier lifestyle as a family. After reading more about the revisions people have had I KNOW I made the right decision with the sleeve.

The surgeon reviewed the 3 options available to me and let me decide. Though he wouldn't say anything because it had to be my choice, I think he prefers the sleeve as well.

Anyway, I will keep you all posted once I find out what happens with the insurance this week and what they require.

Hello all! I am sitting here still waiting to hear from my medical group if I have been approved for surgery or not. In the middle of my research I found a link I wanted to share. I am not sure which plans this applies to but I do know it applies to mine (check your policy). I have United Healthcare *** Sig Value Advantage (used to be Pacificare Sig Value ***). I do know that my policy allows for bariatric coverage. Hope this can help some of you out there with questions. I was originally looking into lapband but decided on the sleeve and was researching whether or not the insurance would cover it. Based on this it does.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Bariatric_Surgery.pdf

Best of luck to all of you.

Cheri

Hi Deb! Thanks for responding! At this point I don't even know if I have a coordinator yet. I contacted United Healthcare 3 times. Yep, 3! The first person I spoke to told me I did not have bariatric coverage! I told her she had better check again because I just saw the surgeon. The customer service people need some serious training. The only thing they could tell me was that bariatric surgery is a covered benefit if it is deemed medically necessary. So now I am just waiting for the authorization from my medical group to approve the surgery and all the pretesting I will need. I think because my visit with the surgeon was for the initial consult only I won't have a problem going with the sleeve so long as the insurance covers that procedure. I verified with the medical group that the surgeon is requesting the sleeve. So as of right now I am sitting and waiting which seems to be the hardest part! I did see on the asmbs.org website that United Healthcare is covering the sleeve. Hope they are right.

Can you tell me a little bit about your experience with the sleeve? Any tips? How do you like it? Does it really take away the hunger?

I have UHC and I originally started the process wanting lap band. Once I went to the seminar I quickly changed my mind to VSG. I called UHC and spoke with my coordinator about how I have changed my mind and I would like to have the sleeve instead. Her only concern was if I was switching doctors. I did not have any problems with getting my sleeve. Have you called and spoke with a coordinator? Good luck with everything!

Deb

Hello all! I am new to this site. I was originally signed up with the lap band forum. I finally had my appt with the surgeon today. I went in thinking Lapband and came out thinking gastric sleeve.

My surgeon has submitted the request for the sleeve. So now I am waiting to see if my insurance will approve the surgery. I have United HealthCare *** which allows for bariatric surgery if it is deemed medically necessary. Which I would think would be obvious if the surgeon is requesting it. Only thing I am wondering now is if they will cover the sleeve. I originally was so focused on the band that I never researched the insurance process for the sleeve. Is it different? According to the insurance there is no specification on a "procedure" other than the medical necessity portion. I have met with the nutritionist already and I know I will have to submit to a psych eval. I fulfilled the diet requirement because I was under a medically supervised diet for 2 years plus I had records for 5 years of a gym membership. Other than that I feel like I am starting all over again. Is there anyone out there who has had a similar experience? Switching from the band to the sleeve midstream? Any information would be appreciated. It was such a struggle just to get the approval to see the surgeon so the fact that I made it into his office after months of trying was a definite plus. So at this point the sleeve is now my first option and if that's not covered the surgeon is going to submit for the lapband. If you have a sleeve I would love to hear about your experience. Any information is appreciated!

I have UHC Sig Value Advantage *** formerly Pacificare ***. I submitted 2 years of medical records to prove that I was under a medically supervised diet and my gym membership records to get approved. I have a BMI of 40 but they wanted to me to show "motivated" attempts of trying to lose weight. They denied me at first because my doctor did not submit the records with the request. As soon as they received the records I was given a consult with the dietician 10/3/11 and a consult with the surgeon 10/6/11. According to my plan I just have to pay for the drs visits $40 copay and a $300 copay for every day I am in the hospital up to $600 total out of pocket per stay. I contacted the medical group and they are not requiring a psych eval at this time. I thought that was a requirement but the lady said only if the dr deems it necessary. So I guess I will just wait and see at this point. Next week can't come fast enough!

I just got the news I am approved for a consult with the surgeon. I jumped through the hoops and finally reached my goal! From what I hear getting the consult authorization to see the surgeon is probably the hardest part of the process.

This is my story. I started 2 years ago. I went through the nutrition courses then I lost my insurance when I was laid off. So now I have UHC West (formerly Pacificare Sig Value ***) through my husband's employer. In July I found out they cover the lap band. I had a BMI of 39 at the time and I have asthma, stress incontinence, fatty liver, heel spurs and low back pain. My doctor was very helpful and submitted the authorization which was denied for lack of medical necessity (I did not have a long history with my new doctor) and they sent me an authorization to see their weight doctor for a medically supervised diet (I did not make the appt because I had 2 years with another weight clinic under my belt). I then appealed and it was denied again. This time saying that my comorbidities were not "bad" enough. I had to have sleep apnea, high blood pressure or coronary problems. The only way I could get covered was if I had a BMI of 40. So I gained the weight, as if I was not uncomfortable enough and I was so mad because I had to gain the 15 lbs I worked so hard trying to lose the last year When my doctor submitted the authorization request it was then denied because I needed to show 6 months of "motivated" attempts for weight loss even though my BMI was now at 41....ummm, hello! I have been dieting since I was 11. My nickname in Jr High was Dexatrim (kids can be mean). Anyway, I turned in my medical records from a medically supervised weight clinic that I went to for 2 years (what a waste of money did not lose a pound) and my 5 years of membership to the gym. This was just on Friday. On Friday at 5pm I received a call from a dietician. I assumed I was finally approved to see the surgeon. But it wasn't until today that I found out for sure that yes, I have been approved. Now I see the dietician on 10-3-11 and the surgeon on 10-11-11. All I can say is get ALL of your documents together before trying to get your authorization approved. It will save you time and frustration.

Now I am sitting here so excited, scared and happy all at the same time. I hardly know what to do with myself! So now my question is what comes next? Anybody out there care to give a newbie some advice? I would really appreciate it!

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<img border="0" src="http://tickers.TickerFactory.com/ezt/t/wJg38Pv/weight.png"></a>

Hello all, I found out that if I get approved through my insurance the surgeon would be Dr. Ramin Sorkhi. Does anyone have any experience with him?

Any info would be appreciated!

About 2 months ago I went to the doctor thinking that with a 39 BMI with asthma, stress incontinence and fatty liver I would be approved with no problem. After being denied and appealing the decision I was again denied. Apparently my comorbidities weren't bad enough for the insurance.

So after reading the evidence of coverage I learned that you have to have a BMI of 40 or over. A BMI of 35-39 had to have specific comorbidities. I just saw my primary doctor on Friday and am now a 41.78 BMI. She is submitting the request for authorization again. I have Pacificare Signature Value ***. I am almost certain I will now receive the authorization to meet with the surgeon. Which brings me to my question. I gained 15 lbs to qualify for the surgery. But I am right on the cusp. Should I attempt to start trying to lose a little weight before meeting with the surgeon or should I wait until I get into his office and have them record my weight first? The extra 15 lbs has made me even more uncomfortable than I already was!

I just am not sure if I drop a single pound that puts me under a 40 BMI that I will be approved.

I guess I am not sure if once I get the authorization to see the surgeon if I am approved for the surgery? Or if I have to see the surgeon first before I get the final approval. Does this make sense? Any help would be greatly appreciated. I feel like I am flying blind right now!

Thanks for the help!

About 2 months ago I went to the doctor thinking that with a 39 BMI with asthma, stress incontinence and fatty liver I would be approved with no problem. After being denied and appealing the decision I was again denied. Apparently my comorbidities weren't bad enough for the insurance.

So after reading the evidence of coverage I learned that you have to have a BMI of 40 or over. A BMI of 35-39 had to have specific comorbidities. I just saw my primary doctor on Friday and am now a 41.78 BMI. She is submitting the request for authorization again. I have Pacificare Signature Value ***. I am almost certain I will now receive the authorization to meet with the surgeon. Which brings me to my question. I gained 15 lbs to qualify for the surgery. But I am right on the cusp. Should I attempt to start trying to lose a little weight before meeting with the surgeon or should I wait until I get into his office and have them record my weight first? The extra 15 lbs has made me even more uncomfortable than I already was!

I just am not sure if I drop a single pound that puts me under a 40 BMI that I will be approved.

I guess I am not sure if once I get the authorization to see the surgeon if I am approved for the surgery? Or if I have to see the surgeon first before I get the final approval. Does this make sense? Any help would be greatly appreciated. I feel like I am flying blind right now!

Thanks for the help!

I have a question for you ladies. I was denied by my insurance for not having a 40 bmi so I gained the weight and just saw my dr. I am at almost 42. Talk about going overboard! Anyway, can I start trying to lose some weight now or do I have to wait and see if I get approved and see the surgeon first? Any help would be appreciated thanks!