HELP! Insurance (United Health Care) Denied Surgery

I am desparate.  My husband's insurance turned him down for the surgery.  He is well qualified for it, but they are stating that it is not covered under our policy.  A woman he works with had it 3 years ago with United Health Care and had no problems getting it covered.  We are just beginning this journey and don't have any idea what to do next.  We spoke with the Benefits Administrator who was very condescending and judgmental and claimed that the policy NEVER covered it even though we work with someone who had it and she used the same insurance.  Has anyone had any luck with appeals and if so, can you give us some advice as to what to do next.  Our surgeon is Dr. Chae. I am very afraid that if my husband doesn't get this surgery, he won't be around much longer.  I love him with all of my heart and we have a new baby.  I really need some help with all of this.  It is overwhelming. Thanks!  I appreciate it.

i had united health care ppo and they denied me 4 times....my dr office recommend i file an appeal through obesitylaw.com...three weeks later i got an approval letter in the mail.  you should really check it out it may help.

You should personally go through your insurance companies requirements. Alot of insurance companies will one year be ok with something and the next year remove that program. It's all about costs, benefits, and profits with insurance companies. You can have the surgery paid through by yourself through cash or have it financed (there are credit cards and loan programs just for weight loss surgery) but not many people can afford that. Medicaid also provides the surgery but then you have to see if you qualify for that insurance and see if you qualify for their requirements for the surgery. The Obesity Action Coalition has a brochure that discusses appealing an insurance denial: http://www.obesityaction.org/resources/insurance/appealingad eniedclaim.php The website has alot of other good resources. Here is an excerpt from the website that seems to fit your situation:

“Excluded Procedure” Categorization In the event the denial was categorized as an “Excluded Procedure,” once again, make sure the correct codes were used. At this point, make sure all factors of your morbid obesity status have been reported, such as co-morbid conditions that affect you (heart disease, diabetes, sleep apnea, etc.). Once you have the correct codes, if they were incorrect, and a letter from your doctor stating your current health condition (including all co-morbid conditions), resubmit (Please click here for a sample letter).

Some insurance providers are limited by the state in which they operate, as to the number of appeals they can accept from patients. If you have reached the maximum number of appeals from your insurance provider, you may be eligible for an external review.

If your state offers external reviews of denials, you have the right to request a review of the HMO’s decision concerning the complaint or appeal within 365 days after receipt of the final decision letter from your insurance provider. For a definition of External Review, please see the Glossary of Health Insurance Provider Terms. Good luck!!!

My insurance policy has an exclusion on it. and everyone thought that proceeding was wasting their time. If he has medical necessity .....file an appeal. The surgeons office should be able to tell you from the person there that does insurance what they need. I had made up my mind to figure a way to pay for it myself (because of the RX savings and food money I would save) but the insurance told me Monday I was approved and gave me an approval number. Having WLS and Needing WLS is to different things I was headed for Dialsis if I did not do something Appeal Fight ask the company to consider Medically necessary wihen they renew the policy and PRAY!!! there is always hope. I have UHC and it is approved!!

I have UHC as well and mine was not covered as well.  It was an exclusion put in the policy by the employer.  They did not have this exclusion 2 yrs ago when I first considered it, but I was of the mentality at the time that I don't need sugery and can lose it on my own.  Two years later I decided I needed surgery to do it and then the exclusion was there.  I ended up doing a home equity loan to pay for it.  My luck is next year it won't be an exclusion again but then again I will be much lighter by then.  But companys can change the coverages every year at open enrollment so it very well could've been covered 3 yrs ago and not now, that was the case for me. 

I had the same problem. About 5 years ago, the company I work for decided to add WLS as an exclusion to their benefits. i was so frusturated as I got caught in the yearly benefits switch. I was covered when I started the process and then when I was able to get the surgery (after all the classes and appointments etc) I was no longer approved. I fought it for aboout 2 years and was denied each time -- even though it was medically necessary. It's very frusturating. If I was too thin, I would have no problem getting coverage for treatment through my employeer.

Anyway, good luck. Keep appealing it if it's medically necessary. Or, payfor it out of packet. They have TONS'O surgery financing companies out there.

Best,
Kristin