Shaei

United Healthcare/Optum - Dr. thinks.....

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Hello all.  I hope that I'm posting this in the right place.  First I apologize if this is too long.....

 

I saw my bariatric doctor on Tuesday and he told me that he didn't think I would meet the qualifications for WLS for my insurance.  I have United Healthcare and we have to go thru Optum and choose a Bariatric Center of Excellence.  When I initially called United Healthcare and forwarded to Optum, I was told that I had to have a BMI of 40 or a BMI over 35 with a comorbidity of high blood pressure, high cholesterol, sleep apnea or diabetes.  No mention was made of whether or not I needed to be on medicine for any of these things or if they needed to be under control.  I went to the first session with the Bariatric center and they took blood and scheduled me for a sleep study.  Blood test showed I was pre-diabetic and anemic but they forgot to check my cholesterol so no answer on that (although my cholesterol has been high enough that my primary care doctor has wanted to medicate me for a few years now), sleep study showed a mild case of sleep apnea.  The bariatric doctor seemed to think that my insurance company may not approve me for the surgery.  He stated that most insurance companies require at least 2 comorbidities and that they be uncontrolled on medication with a BMI as low as mine (it's 37.5).  Now I'm worried that I'll go thru 6 months of supervised diet and end up denied.  I called Optum again today and they said my insurance makes no mention of whether co-morbidities have to be controlled or uncontrolled or that they have to be at a certain level (for instance mild sleep apnea vs severe sleep apnea).  Has anyone ever gotten to the end and been denied because their comorbidities were not severe enough?  I want to believe what the insurance company says but the doctor has been dealing with insurance companies longer than me so I would think he knows what he's talking about.

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United Healthcare Bariatric Surgery Medical Policy for 2014. The first page lists accepted comorbidities and perameters they have to fall within to be acceptable.

 

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

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United Healthcare Bariatric Surgery Medical Policy for 2014. The first page lists accepted comorbidities and perameters they have to fall within to be acceptable.

 

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

 

Thank you for the information!  This document indicates that the Certificate of Coverage or Summary Plan Description may differ from the medical policy so I guess I should contact them directly for one of these additional documents.  I appreciate you pointing me in the right direction,

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Yes, your specific insurance plan rules in terms of limitations and actual coverage. You can obtain your specific insurance plan through your job (if your insurance is provided through work) or online at MyUHC.

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My UHC policy only requires one comorbidity with a BMI less than 40. Its all up to your employer, they pick out the requirements. I didn't have a 6 month waiting period or psych evaluation requirement. They only required that I be over 18, BMI of 40 without comorbidity or below 40 with one comorbidity, and a bariatric center of excellence. I had to enroll in optum but didn't have to do nurse counselling sessions. I got very lucky. Doctor's offices don't always know everything, mine tried to argue my requirements with me and I had to get it in writing for them.

Edited by jtickle

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Thank you JTickle. That's kind of what I was wondering about....could it be as simple as they told me or was the doctor assuming more than the requirement of my insurance? I do have to do the 6 month supervised diet and psych evaluation but he had me thinking that I either wasn't heavy enough or sick enough. I'll keep pressing forward.

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What is your BMI? If it is below 40 and no morbidites, you probably will not qual with UH.

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Hi Basher. My BMI is 37.5 and I appear to have only one mild comorbidity. I checked with Optum tho and they say I only have to have the comorbidity - doesn't matter what severity. I'm still afraid I'll get to the end of this journey and get denied so I'm preparing for an appeal just in case.

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I have UHC/Optum through my employer - I think my plan called for a BMI over 40 OR 35-39 with 2 co-morbidities,  I believe the amount of co-morbidities required and whether they are documented/treated or not depends on the program guidelines specific to your employer if you are using your insurance coverage from work.  When I called UHC, they had someone who was super knowledgeable available to answer all of my questions.  Also, when my surgeon sent the paperwork off to UHC, I was called within like a week or two to be advised of their approval.  My BMI was in the super morbid obese category, all I had to do was show a 5 year history of my weight (Doctor/clinic documentation).  Once it was approved, UHC notified my surgeon the same day that they approved it and the Dr's office called me to schedule my RNY, I didn't even have to wait for the letter to be mailed out. 

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I have UHC/Optum through my employer - I think my plan called for a BMI over 40 OR 35-39 with 2 co-morbidities, I believe the amount of co-morbidities required and whether they are documented/treated or not depends on the program guidelines specific to your employer if you are using your insurance coverage from work. When I called UHC, they had someone who was super knowledgeable available to answer all of my questions. Also, when my surgeon sent the paperwork off to UHC, I was called within like a week or two to be advised of their approval. My BMI was in the super morbid obese category, all I had to do was show a 5 year history of my weight (Doctor/clinic documentation). Once it was approved, UHC notified my surgeon the same day that they approved it and the Dr's office called me to schedule my RNY, I didn't even have to wait for the letter to be mailed out.

Same with me. They called me the day I was approved and the doctor's office the same day. My surgery was scheduled the same afternoon. The people at UHC and optum were very helpful.

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Hi Basher. My BMI is 37.5 and I appear to have only one mild comorbidity. I checked with Optum tho and they say I only have to have the comorbidity - doesn't matter what severity. I'm still afraid I'll get to the end of this journey and get denied so I'm preparing for an appeal just in case.

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Hi Stacymeyer1. I did indeed get the approval and had surgery on February 10th. My experience with Optum was a mixed bag but the last case manager I had was fantastic. She kept me in the loop nd let me know anytime additional info was needed. I'm now on the losers bench and looking forward to better health.

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Wow nice Shaei! Best of luck to you. Mine was submitted on the 10th to UHC but haven't heard anything yet. Seems like eternity. I have my pre op date and surgery date set already which will be March 3. I hope I get an approval before them. So is optimistic going to contact me? I never heard about them.

How long did it take for you approval from the date they submitted it?

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I was told the approval would take about 14 days but I believe it was about 7 days in my case. The doctor's office actually called to give me the results. Optum just sent me a one paragraph letter saying I was approved. I had mixed feelings about that but the fact that I was approved made me forget about it pretty quickly.

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I also have United healthcare, my surgeon told me he wasn't sure if they'd cover the revision.

But on January 15 I got the approval from my insurance company, and my surgery is tomorrow!!!

Good luck!

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I also have United healthcare, my surgeon told me he wasn't sure if they'd cover the revision.

But on January 15 I got the approval from my insurance company, and my surgery is tomorrow!!!

Good luck!

Best wishes for a speedy recovery.

Sip, sip, sip

Walk, walk. Walk

The more you walk, the better you will feel.

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Best wishes for a speedy recovery.

Sip, sip, sip

Walk, walk. Walk

The more you walk, the better you will feel.

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Best wishes for a speedy recovery.

Sip, sip, sip

Walk, walk. Walk

The more you walk, the better you will feel.

Thank you! I will keep in touch with my progress.

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I have united healthcare/optum as well. I am just beginning the journey I have a phone call scheduled with my nurse on 3/11 and the bariatric appointment 3/18. I am just wondering what everyone's out of pocket cost is?

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On February 18, 2015 at 9:39 AM, trishschaff1 said:

I also have United healthcare, my surgeon told me he wasn't sure if they'd cover the revision.

But on January 15 I got the approval from my insurance company, and my surgery is tomorrow!!!

 

Good luck!

Can you tell me HOW they approved your revision? Do you have UH Community Plan? I read the info posted here from their handbook and they said they would only approve revisions with a BMI of 40. My BMI is not that high but I desperately need to have my sleeve converted to a RNY for TERRIBLE acid reflux that has now become Barrett's Esophagus! I just finished a long battle with breast cancer 2 years ago and am scared to death that I will now get cancer of the esophagus! Does anyone have any info on revisions with UH Community Plan??

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With severe GERD, Barrett's Esophagus and a history of cancer, don't worry about what your policy says. Just start the process and assume that you'll get a denial first pass. Then wait for your surgeon to do a peer to peer review. I can't guarantee anything, but I also can't imagine them denying surgery to someone who truly needs it.

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