Hi! I’m new to the forums. I am hoping to have WLS this year. Somewhat ironically, I work in Prior Authorizations for a health insurance company, so I’m very familiar with what it means to require auth. However, every company is a bit different.

I’m a newlywed and my husband added me to his policy. This was planned as my previous coverage was not as good, and his plan covers bariatric surgery whereas mine did not. So we now have UHC Choice through T-Mobile.

I have checked the coverage requirement thoroughly and have a couple concerns:

A. They require a 5 year weight history. However my coverage before this has been fairly bare minimum. So I mostly only went to the doctor if absolutely needed. And the eye doctor, who does not weigh. How strict are they on having a five year history? Do I only need a couple weigh ins throughout that time? Or multiple a year etc? Also will they accept photo documentation or a written statement? I mostly gave up on getting help from my PCP’s previously as they’d tell me I “wasn’t trying hard enough” whenever I failed to lose weight. But I just established care with a great PCP in order to get everything checked out/ruled out prior to asking for a referral and recommendation for the surgery.

B. I know when I’m ready for a consult etc. I will need to go through UHC Bariatric Resource Services through Optum. What is it like working with them? Do they actually help and guide you as if they’d like for you to get approved?

thank you in advance!

just to note:

My BMI is over 40, and has been at least over 35 my entire adult life. I have attempted weight loss with phentermine multiple times, as well as keto, weight watchers, and CICO. I have hypertension, hyperlipidemia, exertions dyspnea, chronic back problems, and chronic muscle tension. I am active and I do watch what I eat, just fail to lose significant weight. When taking weight loss medications I lose up to 20 lbs, but then regain as soon as I go off the med even when sustaining my same lifestyle.

Edited February 13, 20206 yr by Deemarie1221

Hi! I’m new to the forums. I am hoping to have WLS this year. Somewhat ironically, I work in Prior Authorizations for a health insurance company, so I’m very familiar with what it means to require auth. However, every company is a bit different.
I’m a newlywed and my husband added me to his policy. This was planned as my previous coverage was not as good, and his plan covers bariatric surgery whereas mine did not. So we now have UHC Choice through T-Mobile.
I have checked the coverage requirement thoroughly and have a couple concerns:

A. They require a 5 year weight history. However my coverage before this has been fairly bare minimum. So I mostly only went to the doctor if absolutely needed. And the eye doctor, who does not weigh. How strict are they on having a five year history? Do I only need a couple weigh ins throughout that time? Or multiple a year etc? Also will they accept photo documentation or a written statement? I mostly gave up on getting help from my PCP’s previously as they’d tell me I “wasn’t trying hard enough” whenever I failed to lose weight. But I just established care with a great PCP in order to get everything checked out/ruled out prior to asking for a referral and recommendation for the surgery.

B. I know when I’m ready for a consult etc. I will need to go through UHC Bariatric Resource Services through Optum. What is it like working with them? Do they actually help and guide you as if they’d like for you to get approved?

thank you in advance!

So I have UHC but through a different company obviously. I worked with a Bariatric Center of Excellence where I live. I need 6 months of consecutive doctor visits where I was weighed and we discussed my weight and health concerns. for me, this was not difficult because I was suffering from severe stomach issues, including gastroparesis, which is why I was recommended for the surgery in the first place. I had also had consecutive visits with a endocrinologist for my PCOS. They did not require the 6 months to be from the date of, but could also be backtracked. In your case since you may not have this history, you may need to start from the beginning. But 6 months is not bad and it goes very quickly trust me.

UHC also required three consecutive months of visiting with the nutritionist. This can be done in tandem I believe with the 6 months of doctor visits. You need to show that you can change your habits and lose weight during this time with the nutritionist. they also require that you meet with a psychologist to evaluate if you're mentally healthy enough for this surgery and the life changes it will bring.

I did have to deal with Optum as well on their side, and never had an issue. I had to speak with a nurse for a few months and she would keep up on where I was, let me know where the process was on their end, and they did some follow-up post surgery. I really had no problem with them at all. They were very nice.

All in all my process was very smooth, I had no issues getting approved, and it went quickly. I am not sure if part of that was because of how well the bariatric center was run, but I am very pleased with both United healthcare and my center. I did have to pay some out of pocket for vitamins and some hospital copay, but it was under $500.

I hope this answers your question as best as I can, I realize that the insurance coverage may be different depending on the company and the program. But if you have any other questions let me know.

I have UHC Choice Plus and have just chosen my surgeon and started scheduling the various appointments required, thus starting that six month insurance clock. From everything I have researched and been told by the Bariatric Center, BadWolfGirl is correct. I have had the same information and instructions. I must meet monthly for Weight Management Classes where we weigh in and can't gain any weight and try to lose, do a Psych eval, get a cardiac release from my Cardiologist, meet several times with a Nutritionist (I can't remember how many, but may pay for some extras, because I am f-ing serious about this), get some records from my Pulmonologist re: sleep apnea/ my biPap, i am having a lapband removed and revised to RNY, so I may have a couple extra requirements - that is not 100% set, yet. I haven't had to deal with Optum yet. My Bariatric Center has been around for years here in Houston and I have confidence in them. I hope that confidence is not misplaced. It's a good size practice in a large city in the Houston Medical Center, so they had better know! So, I have not been told that I need to document my weight other than the six month period - I could if they just need a number recorded annually from a doctor.

I have never had any issues with UHC in the past for other things, so don't anticipate any going forward. The worst that has happened is that UHC has cut ties with a large hospital system in Houston and half of my doctors are employed through that system. Sigh. Both called the other's bluff and unless they come to terms in a couple months, I need some new docs. Surgeon is fully covered, thank God.

So I have UHC choice plus. They told me over the phone that they required the 5 year weight history, 6 month diet visits and so on. But I went and looked at the policy online and saw that they had revised their policy and guidelines at the end of the year this past year. In the revised policy, there was no 6 month diet needed and no mention of the 5 year history. So I called again to verify that and they told me no, that I needed the 6 months diets and blah blah blah. So..... I saw my surgeon for the first time to get this all started on dec 27. The nurse told me she would just send in for the prior auth and see what they came back with. When she sent in for the prior auth, all she had was my 1 office visit with them, my psych eval and that was it! I got approved in 4 days.
Yes, it has to be at a center of excellence facility and you do have to have a psych eval, but @momotrips3 and @Deemarie1221 I would strongly recommend requesting they just send in the prior auth once you have those. At least they will tell you for sure sure what they need for approval.
the nurse at my surgeon’s office told me that sometimes policy changes and that new info doesn’t get passed down to all of the customer service representatives but the people who are actually approving or denying should know what they are doing.
anyways This is just my experience and hope this helps!

33 minutes ago, Puffy-no-more said:

So I have UHC choice plus. They told me over the phone that they required the 5 year weight history, 6 month diet visits and so on. But I went and looked at the policy online and saw that they had revised their policy and guidelines at the end of the year this past year. In the revised policy, there was no 6 month diet needed and no mention of the 5 year history. So I called again to verify that and they told me no, that I needed the 6 months diets and blah blah blah. So..... I saw my surgeon for the first time to get this all started on dec 27. The nurse told me she would just send in for the prior auth and see what they came back with. When she sent in for the prior auth, all she had was my 1 office visit with them, my psych eval and that was it! I got approved in 4 days.
Yes, it has to be at a center of excellence facility and you do have to have a psych eval, but @momotrips3 and @Deemarie1221 I would strongly recommend requesting they just send in the prior auth once you have those. At least they will tell you for sure sure what they need for approval.
the nurse at my surgeon’s office told me that sometimes policy changes and that new info doesn’t get passed down to all of the customer service representatives but the people who are actually approving or denying should know what they are doing.
anyways This is just my experience and hope this helps!

Wow! Yes, the last time I called was before the new year. I can understand that they "know" the requirements, so this close to the new year, these things could get overlooked. That would be great! I'd still like to take a little time and get some face time with the Nutritionist, but if I could choose early May instead of June or July that would be clutch! I've got some commitments until mid April or I'd say sooner. I'm going to check with the surgeons office and see what they say. Thanks again!

I have UHC Choice Plus as well! However, the insurance isn’t requiring me to do the 6 months at all. The only requirement really is being morbidly obese or 50% greater than your ideal body weight. My paperwork gets submitted after my March 3rd appointment with the psych. I hope everything goes well for you!!

21 hours ago, Puffy-no-more said:

So I have UHC choice plus. They told me over the phone that they required the 5 year weight history, 6 month diet visits and so on. But I went and looked at the policy online and saw that they had revised their policy and guidelines at the end of the year this past year. In the revised policy, there was no 6 month diet needed and no mention of the 5 year history. So I called again to verify that and they told me no, that I needed the 6 months diets and blah blah blah. So..... I saw my surgeon for the first time to get this all started on dec 27. The nurse told me she would just send in for the prior auth and see what they came back with. When she sent in for the prior auth, all she had was my 1 office visit with them, my psych eval and that was it! I got approved in 4 days.
Yes, it has to be at a center of excellence facility and you do have to have a psych eval, but @momotrips3 and @Deemarie1221 I would strongly recommend requesting they just send in the prior auth once you have those. At least they will tell you for sure sure what they need for approval.
the nurse at my surgeon’s office told me that sometimes policy changes and that new info doesn’t get passed down to all of the customer service representatives but the people who are actually approving or denying should know what they are doing.
anyways This is just my experience and hope this helps!

Gahhh I hope it only takes them 4 days for me lol. I’m hoping to get an April date!

1 hour ago, danielleleigh90 said:

I have UHC Choice Plus as well! However, the insurance isn’t requiring me to do the 6 months at all. The only requirement really is being morbidly obese or 50% greater than your ideal body weight. My paperwork gets submitted after my March 3rd appointment with the psych. I hope everything goes well for you!!

I actually have UHC Choice not Choice Plus. I’ve heard so many good things about the process with Choice Plus, so I’m hoping regular Choice isn’t too different. Plus really just hoping the five year history doesn’t screw me over... but it sounds like most people haven’t had issues with the history requirement with UHC!

I contacted my patient coordinator today. Hopefully she'll get back to me soon. I am not exactly 50% higher than my ideal weight, but I am BMI 40 which is supposed to not require comorbidities as a consideration, even though I have at least one - sleep apnea and a biPap machine. My weight when I was in high school and in my mid 20's was only 10lbs higher than half my weight and I was always curvy, so I don't really know what my ideal weight really is. So who knows!

11 minutes ago, Deemarie1221 said:

I actually have UHC Choice not Choice Plus. I’ve heard so many good things about the process with Choice Plus, so I’m hoping regular Choice isn’t too different. Plus really just hoping the five year history doesn’t screw me over... but it sounds like most people haven’t had issues with the history requirement with UHC!

Also, good luck!

10 hours ago, Deemarie1221 said:

I actually have UHC Choice not Choice Plus. I’ve heard so many good things about the process with Choice Plus, so I’m hoping regular Choice isn’t too different. Plus really just hoping the five year history doesn’t screw me over... but it sounds like most people haven’t had issues with the history requirement with UHC!

Sorry for the misread, Hopefully they are easy as well! I’ve read of some people on the forums saying that if there is no history of the 5 years, they’re able to get by with doctors saying it’s necessary and doing the various months required of supervised visits. Hopefully everything works out! Keep us posted! ❤️

10 hours ago, momotrips3 said:

I contacted my patient coordinator today. Hopefully she'll get back to me soon. I am not exactly 50% higher than my ideal weight, but I am BMI 40 which is supposed to not require comorbidities as a consideration, even though I have at least one - sleep apnea and a biPap machine. My weight when I was in high school and in my mid 20's was only 10lbs higher than half my weight and I was always curvy, so I don't really know what my ideal weight really is. So who knows!

I said the same! My “ideal” body weight is said to be 127 (by my doctors). However even in adulthood I’ve only been about 150. I was super worried initially because my BMI is around 37, but I have confidence that when combined with family history of diabetes, cardiovascular disease & my depression & anxiety (that’s gotten increasingly worse since I’ve gained so much over the past 10 years) aaand my attempts at every diet under the sun, I will be approved. Hope we make it there together!