HELP........Need your advice!

I am a State of Arizona employee, have united healthcare, and have been denied for Gastric Bypass surgery. This whole process has been so stressful and the insurance has not been real helpful in directing me. My BMI is 39.7, I have Hypertension that has been difficult to treat, requiring anti-hypertensives, I am also hyperlipidemic, have uncontrolled diabetes requiring 200 units of Lanus 2x's daily, oral medication also. I have likesleep apea and required to use a c-pap machine and have Gerd. If anyone has been successful with dealing with the State of Arizona, United healthcare, epo plan, please contact me. Thank you so much, Vicki

I work for the state also, but got my surgery back when we were covered by Cigna. Cigna was nightmare also and I ended up hiring an attorney. What was the denial reason? I'm still confused about whether or not it's a covered procedure for state employees these days. Connie

Thank you so much for responding. I have had so many reasons given to me that I am not quite sure. Today I was told that there is an exclusion for state emplyee's regardless of the reason. By one person at united healthcare, I was told it had to be a medical neccessity. So I'm really at a loss. Vicki

Vicki, They are supposed to send you a letter giving the denial reason. You have three opportunities to appeal their decisions. If it comes to it, the third appeal is done through a third party and the state insurance board gets involved. In almost all cases, there has to be a medical necessity. Have you asked for the detailed benefits coverage book yet? Ask UHC for the denial letter that you are entitled to and also ask them for a copy of your benefits coverage. That will help you decide what steps to take next. Connie

Hi, Vicki, I really don't know anything about United Healthcare but I'm wondering if you had your doctor write a letter of medical necessity. Seems to me with your issues it would be a given. Good luck, Virginia

Thank you for you insight. My doctor has written the letter of medical necessity. I will starting my second appeal today.........with another letter from my doctor. I'm keeping my fingers crossed. thank you, Vicki

Vicki, My understanding of the State UHC is that they have a "direct exclusion" written into their benefits package. .... United Health Care as a "blanket" insurance comopany does approve Weight Loss Surgery with just 3 requirements. 1. Letter of medical necessity from your pcp. 2. Psych Eval. and 3. a Current History and Physical (done at your consultation by your Bariatric Surgeon). They have the standard 40 BMI requirement with leeway given to those in the 35 to 40 BMI range with co-morbidities. So, sometimes, if people call UHC then they are told that the surgery is covered. Then they go through the process only to find out that it isn't covered per their employer who may have purchased an exclusion adendum. Some people have actually hunted for new jobs where insurance does cover the surgery. I will check things out when I go in to work tomorrow. It seems like there was a case that was recently approved through the state somehow. If so, I'll let you know the details! Hang in there! Insurances change their pre cert specifications all the time! Huggggzzz, Joyce

Joyce, Thank you so much for lifting my spirits. I will be waiting and hoping to hear from you, even one case approval will give me hope. Thank you, Vicki

Vicki, Checked it out today and we've had 2 recent approvals from the state UHC. Both were denied the first time and both required the patients to go for a sleep study. ..... They have strict doctor supervised guidelines for a 6 month diet. Everything else seems to be about the same. .... If your surgeon is willing to do a peer to peer conference with the pre-determination board in your behalf then you'll have a good chance. Hang in there! Your life is worth it! Joyce

Hi Vicki Katie on this board appears to have the same insurance and she was originally denied and then approved after her sleep test? She is also a patient of Dr. Blackstones.........don't give up!! Cathy