Anyone successful in an appeal to United Health Care?

[sassyatty 0]

Hello Everyone -

I am new here but have been reading posts on this board for months now. I just got denied from United Health Care EPO Choice Plus today. I am extremely upset and am looking for some appeal success stories. I was not approved due to the fact that my BMI is 38.2 and I did not have evidence of any co-morbidities. My policy covers those individuals with a BMI of 35+ if there are one or more co-morbidities present.

I am planning an appealing as I do have a family history of heart disease and diabetes, and I also have knee, back, hip and foot pain. I have not seen an orthopedist for the joint health issues but plan to do so if the medical diagnosis would help the insurance company approve my sleeve surgery.

Has anyone here been successful with a UHC appeal? If so, coul you tell me a bit about how you did it and what information you submitted?

Thanks in advance!

[lisabug 10]

Have you done a sleep study? A lot of people have sleep apnea and do not know it. I think it is crazy that the insurance companies want you to be sick before they will do anything. What happen to prevention? Good luck with your appeal. Maybe your surgeon's office will be able to help you. They deal with this every day.

[Vicki 0]

Hello Everyone -

I am new here but have been reading posts on this board for months now. I just got denied from United Health Care EPO Choice Plus today. I am extremely upset and am looking for some appeal success stories. I was not approved due to the fact that my BMI is 38.2 and I did not have evidence of any co-morbidities. My policy covers those individuals with a BMI of 35+ if there are one or more co-morbidities present.

I am planning an appealing as I do have a family history of heart disease and diabetes, and I also have knee, back, hip and foot pain. I have not seen an orthopedist for the joint health issues but plan to do so if the medical diagnosis would help the insurance company approve my sleeve surgery.

Has anyone here been successful with a UHC appeal? If so, coul you tell me a bit about how you did it and what information you submitted?

Thanks in advance!

Hi there! I have a 7 month story about all this. I have the same exact insurance as you do. I went thru hoop after hoop after hoop. My BMI is the same as yours. I did the sleep study, endoscope, EVERTHING that I was told to do. Just last week I was denied. Thud. Couldn't believe it. The appeal has been sent.....keeping my fingers crossed but I do not have a good feeling about this. Sooooo I checked into the idea of going to Mexico. I AM having the surgery one way or the other. And here I sit. They are to have an answer for me by this friday. I have found a great group in Mexico just in case. Whats a girl to do. I will let you know how it all works out. Hang in there. File your appeal and pray.Best of luck to you. Vicki

[M2G 1,836]

I was just approved today by UHC. I called back in April and was assigned a bariatric case manager and a bariatric nurse manager both from UHC. They have helped through this whole process. My BMI is 44 and I have no co-morbidities.

The information I have from them lists surgery will be approved on the following basis:

Class III obese (BMI > 40)

Class II obese (BMI 35 - 39.9) in the presence of one or more of the following:

- Type 2 diabetes

- Cardivascular disease (e.g. stroke, myocardial infarction, stable or unstable angina, pectoris, hypertension or coronary artery bypass)

- Life-threatening cardiopulmonary problems (e.g. severve sleep apnea, Pickwickian snyndrome, obesity-related cardiomyopathy)

So I imagine that if your BMI is between 35 and 39.9 without at least one co-morbidity listed then it will be denied. Sorry.

I'm surprised that they didn't give you at least a case manager to walk through this with you and give you advice, etc.

[sassyatty 0]

Thanks everyone. Mommy2girls...first off CONGRATS!!! That is wonderful news. I was not assigned a case manager through UHC as my policy does not have the bariatric resource services as a benefit. Only persons with this benefit are given the case manager through UHC. I am trying to do everything I can to establish enough supporting evidence for an appeal...but it is discouraging to say the least. But I will just do what I can do and leave the rest up to God. We'll see what happens.

Thanks again for the information.

[Firefly2 9]

Good luck Sassyatty!!! and congrats Mommy2girls! I am also in the process of getting my sleeve approved and wont' have all my pre-op done until the beginning of December, but I am with Aetna. Aetna has strict rules and says that you have to be 40 bmi or greater for the past 24 months or 35 bmi with co-morbidities. It sucks that you have to jump through so many hoops but I would definitely call and talk to someone at UHC about it and see what you can do to be approved. Good luck!!!! -Tiffany

[drake1219 0]

Have the Dr. recheck your height... I was denied by UHC due to a 38.9 bmi and no co-morbidities.. Had my sleep study done and it came back that I have obstructive sleep apnea. Also had the dr. check my blood sugar levels, seems that I am pre-diabetic ( diabetes also runs in my family). He wrote me a script for metformin and told me it was my choice to use it or change up my diet..chose to do it on my own as I never really had signs of low/high sugar levels. biggest kicker of all was my height.. always thought I ws 5'8..turns out when I asked to be re-measured I am really 5'7 which makes a huge difference with the BMI #s..(put me over 40) this was all charted and sent in to my patient liason who did my appeal to the insurance for..1 week later I was approved for the 25th of Oct. good luck w/ your appeal..keep fighting, just make sure u get all the paperwork and everything in order before sending in your appeal... Chelaine

[Beth 0]

I was denied by UHC too but for a different reason. I did meet the BMI requirement but didn't have 5 years of physician documentation of morbid obesity. I went to my PPO to talk about writing a letter in support of my surgery. She wrote the letter which included my diet history for the past 5 years, knee pain, previous hypertension, and GERD. The letter was included in the second appeal and I was approved within a week. I think including a letter from your PPO will go a long way in winning. I think insurance companies count on us quitting after the first denial. Don't give up!

[sassyatty 0]

I just wanted to update everyone who was kind enough to respond to my initial post. I just got the news from UHC that my appeal was granted and my surgery has been approved!!! I feel like 1,000 lbs. has been lifted off of my shoulders and am just so thankful that I did not throw in the towel!!! I was remeasured and reweighed at the Dr.'s office I was visiting for an evaluation for sleep apnea, and those numbers put me over the BMI of 40 threshold that UHC required for approval. WooHoo...no I just need to get my surgery scheduled and I will be on my way.

Thanks again for your help and advice...it all worked out in the end!!!

[Beth 0]

Awesome!!!! See you on the loser's bench soon!

[M2G 1,836]

Woo Hoo! That is wonderful news. SO glad you didn't give up!!!