Daisymae

Got denied by UHC and I'm Angry!

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I actually have the EPO, so as long as it's in network I get the benefits with very little in the way of deductibles or co-pays.

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The "rules" of batriatric approval are written in the POLICY,  UHC is a hugh company and each employer can be different,  I have UHC with the hospital that I work for, but the plan is self-insured and that means that they (the hospital/employer) can make any rule they want.    I was shocked to learn that they included ONE BARIATRIC procedure in a lifetime, no matter who and what did the first one.  I had to fight them because of complications of the band,  that needs to come out.   IT all worked out, but i have found that the only similarities in UNITED Health care between me and someone else is just the name,  the RULES may be different.      As far as weight loss hx,   they didn't even ask for it,  but other people here had to do 6 months. 

 

The actual POLICY is not something that is readily available, but worth downloading and looking at,  usually 1000 pages or more.  Covers everthing from baby birth to at home care, or nursing home care.  You may be surprised at what your employer WILL NOT COVER.  

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I also got denied because of the 6 month diet (I have UMR).  I sent in my appeal letter last week stating that I had talked to 3 different customer service reps (one of them a senior customer rep) and all of them told me the same thing that I didn't need it.  It's not our fault when they can't tell you what you need and I also believe that it should be in their insurance book that you get at your company, mine said nothing (I read it 3 time cover to cover).  I now have to sit and keep my fingers crossed.

Hello!  I'm new to this site and looking for some help.  I just found out of the weekend that UHC is now saying that I have to have a six month supervised diet pre-op.  When I called and verified what was required for WLS in November 2013 I was told that I would not have to have the 6 month supervised diet.  I now have to send in an appeal letter.  Did you get UHC to accept your appeal?  Do you have any suggestions regarding how to write the letter?  Any help would be appreciated............Thanks, Tammy

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I have UHC Choice Plus. I am only required to over 18, bmi over 40, and bariatric center of excellence. However, I went to my first appointment and the doctor's office argued with me about my requirements. They kept telling me I had to do the six month diet and optum's nursing sessions. I had to get it in writing what my requirements were. Hopefully that works and they submit after I get to do my labs. If something screws up and I end up having to do a diet, I am going to freak out on someone at the insurance company. After I get done having a fit, I will do the diet because I several co-morbidities.

Edited by jgrey1

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TALKING ABOUT INSURANCE COMPANIES, ETC...I'VE BEEN ON METRO'S HEALTH PLAN SINCE I BEGAN AND IT ENDS APRIL 30TH! I'VE JUMPED THRU SO MANY HOOPS, WENT TO SO MANY APPT., COMPLETED OVER 6 MONTHS OF A PRE-OP DIET, LOST 24.5 LBS..BMI WENT FROM 51 TO 45.5. NOW I'M BEING TOLD THAT BECAUSE MY BMI IS IN THE 40'S..I MAY NOT BE ABLE TO HAVE MY WLS  :( ..ALL THIS WORK, AND THEN SOME...KEEPING LOGS, ETC. FOR WHAT? FOR WHO? AND """WHAT COMPANY SHOULD I GO WITH"""""?????? BEEN HEARING SOME AWFUL THINGS ABOUT BUCKEYE, MOLINA, AND SOME OTHER ONE..NOT SURE IF ITS UNITED HEALTH CARE...

 

WHAT TO DO?

FIGHT

FIGHT

FIGHT  :mad: 

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Some insurances make you go through a 3 month or 6 month supervised diet plan. I had a relative that had to wait 6 months and she checked in with her surgeon every two weeks for 6 months and that was considered a supervised diet. Luckly Blue Cross Blue Sheild dropped their wait period in Feb and I did not have to go through this. I know how frustrating it can be when you finally decide to go through with the surgery and then be told you have to wait another 6 months before you can even submit your claim. Good luck and the 6 months really will go by faster than you think.

MAY I ASK WHICH PROVIDER YOU HAVE? AND IS IT ST VINCENT HERE IN CLEVELAND?

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I actually have the EPO, so as long as it's in network I get the benefits with very little in the way of deductibles or co-pays.

WHATS A FPO?? LIKE A HMO?? IM HERE IN OHIO

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I didn't have to do a 6 month diet. I had to do 6 consecutive monthly sessions with a RD and at the end she had to submit all 6 sets of progress notes.

 

Lose or gain, that's all the insurance company wanted. I had the weight history part of it, already, separate from the RD appointments.

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I am so very sorry to hear you were denied...I have UHC as well.  What I would recommend is to contact UHC and get a copy of the guidelines according to your group.  Having a clear understanding of the requirements according to your plan is key.  Even two plans within UHC or any insurance company can be different from group to group. I had the hardest time getting my surgeons office to understand that I literally had to say listen I understand MOST insurance companies require XYZ but my group guidelines within UHC is quite different so hear is a copy of the guidelines according to my group.  

 

Even though you have been denied you can definitely fulfill the requirements according to your plan and have your surgeons office to submit your request for approval at that time.  I am surprised the surgeons office didn't verify what the requirements were for bariatric surgery from the beginning/prior to submitting for approval.  I know you are angry and I know this is beyond frustrating but view this as a bump in the road along your WLS journey and press forward.  Hang in there this can still be salvageable. 

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My UHc Insurance had an exclusion on gastric bypass so I will be paying for mine out of pocket plus I have to pay deductble on endoscopy that and copay get expensive

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Having a Choice Plus plan will not tell you the requirements for each policy. The employer plays a large role in what is covered and any requirements. Check your benefits online or the number on the back of your card to check your benefits. They should be able to tell you what is required. 

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