Denied-for the second time!

Denied by UHC-for the second time and for the same reason.  I don't have 3 years of medically supervised weight Loss under my belt.  I don't understand the denial.  I had a wonderful appeal letter and my doctor wrote to say this would save my life.  But-I am not upset on the denial so much as upset at how they did it.  The first appeal was to be done by a independent doctor in a related field.  You want to know what the doctor's related field was???? Cardiologist and thyroid specialist.   REALLY?????  How related is that????    I am so mad I could spit!!!!  How do I do this second appeal.  I tried to show I had all these years of trying to diet.  I showed on paper I had years of different diets, weight loss products, medications-but no!!!  This insurance states that it has to be 3 years consecutive medical supervised weight loss program.  What do I do???  I can't think, I can't feel anymore.  I am willing and ready for the fight, but I don't know if I will just hear the same answer again.  Anyone else dealt with this?  Any information would be helpful.

Thanks so much

Linda

Self pay was my only option.  I researched for 9 months, and decided to go to Mexicali, Mexico, to see Dr. Alberto Aceves.  His patient reveiws are excellent.  Beautiful clean, hospital, and treated like a queen.  Instead of shoving you out the door in two or three days like in the states you get to stay six nights.  I would do it again in a minute.  I told my husband I wish I could go there for anything surgical I needed...lol  His fee is thirteen thousand.  Sorry, I dont mean to sound like an advertisment, but I love my Dr.  Ive lost 117 pounds in five months.  I do have a ways to go, but I am determined to do it.  He is a very conservative cutter.  He doesnt do real short common channels......Mines 100, and I had to ask for that he wanted to do 125...  He is very cautious...

How I wish I could do self pay.  But it is not an option.  My husband is disabled and I am the only worker in the home.  All our savings went to pay medical bills for him and myself.  the only way I can get this surgery is if my insurance will pay for it.  So, I keep fighting. 

Sorry to hear your having a rough time of it.  My husband had to take a medical disability a couple of years ago, so I really do understand.  We had to take the money out of his 401k , we were glad it was there to take, but hated taking it out.  I wish you luck.  Sometimes things take awhile to fall into place.  I waited over ten years before I was able to get mine done.  I honestly had givin up hope, and then we found a way.  Dont give up.... wishing you the best of luck.....

I would contact lindstrom obesity advocates. You can find them in a google search. Often they will listen to your case over the phone and advise you. They will often make a call to the insurance that changes the deal. They will allow payment plans for their services.

I used them, it get no kickback from them. My case was unsuccessful but it was an exclusion and those are impossible to beat.

GL it is worth a phone call

Question:  Does your policy actually SAY that 3 years of a medically supervised diet is required?  I would be sure that I had a copy of the policy in hand and find the statement.  If not, you can argue against it.  My insurance stated a 6-month supervised weight loss program was required, yet that was not stated in the policy.  While I got busy writing letters and talking to my assigned case worker about that, I started seeing my PCP every month and documenting my visits.  I had him make chart notes on the form that was required by my insurance company.  The issue was resolved by my 3rd month, and I was allowed to proceed without the documentation.

The Wall Street Journal has an article here that talks about appeals:  http://guides.wsj.com/health/health-costs/how-to-appeal-a-he alth-insurance-denial/

Also info from ASMBS here:  http://asmbs.org/2012/01/preoperative-supervised-weight-loss -requirements/

Sometimes insurance companies will AUTOMATICALLY deny, no matter what is presented in your appeal.  They delay in hopes that you will go away.   It helps to call and speak with someone about your denial.  Ask questions.  Be polite but firm in your resolve.  For example, tell them that you want to appeal again and you want to know if they will allow a bariatric physician who performs the DS to review your request.  Ask what happens if your second appeal is denied.  In the state that supervised my policy, the 3rd and final appeal is independently reviewed.  I'm betting they hope you will give up before it gets this far. 

Best wishes to you and good luck!

Here is the pre-requisites for Obesity Surgery from my insurance company:

Obesity Surgery The Plan covers surgical treatment of clinically severe obesity (morbid obesity) provided by or under t he direction of a Physician provided all of the following are true: you are at least 25 years of age; you have a minimum Body Mass Index (BMI) of: 50 and considered to be super obese; 40 for 3 years or more; or 35 with complicating co morbidities directly related to, or exacerbated by obesity, such as: hypertension requiring medication for at least one year; type 2 diabetes requiring medication for at least one year; obstructive sleep apnea, confirmed by a sleep study, which does not respond to conservative treatment; cardiovascular disease; and pulmonary hypertension of obesity; you have a documented history of failure to sustain weight loss with medically supervised dietary and conservative treatment for at least 3 years; you are an acceptable operative risk; and you have been evaluated by a licensed mental health provider who documents that you are motivated to follow all necessary pre-operative and post-operative treatment   The highlighted area is the area is the  one thing that is keeping me from this surgery.  When this whole thing started, I questioned this part.  I was told by my insurance customer service reps that this meant that I had to show that I had 3 years of weight loss attempts.  I have been overweight since I was 6.  I have had so many attempts and have tried many doctor diets but in the last 9 years, I figured that everything I have tried didn't work so I didn't try anymore medical tries at weight loss but I did try to maintain my weight on my own.     I proved that I have done 3 years of medical attempts but they were not consecutive.  My denial stated that it had to be consecutive.  I appealed that I indeed had 3 years and more of attempts.  They denied my appeal based on the fact that I cannot show proof of medical.  My doctors did not put it in the records.  I usually went in for blood pressure checks and labs and talked to the doctor about weight but the records only showed the codes for the checks or labs.  So- I can't prove it.  I am so upset but I am going to keep trying.  My next step is going to appeal to my insurance department of my work since my insurance is self funded.  Wish me luck.

Linda, I'm including a link here to UHC's general medical policy for bariatric surgery effective 10/1/13. 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

This policy states: "Documentation of a motivated attempt of weight loss through a structured diet program, prior to bariatric surgery, whi*****ludes physician or other health care provider notes and/or diet or weight loss logs from a structured weight loss program for a minimum of 6 months. (NHLBI, 1998)"

Granted YOUR specific UHC policy is stating different requirements but my point here being that perhaps you can use this as reasoning in your next appeal.  Alternatively, if your company's policy is "self-funded" (you can find this out by asking HR or asking your UHC customer service rep), then you can request that your company change its policy language to conform to the more generally accepted guidelines as shown in the linked UHC policy.

I am not an insurance guru by any means, but it does sound like your company has implemented more strict guidelines for qualifying than what UHC typically requires.  My sister and I both had the DS with UHC with guidelines similar to those in the linked document.

Three years of a medically supervised diet seems just plain unreasonable.  Especially if you have comorbidities that put you at further health risk.  I wish you the best of luck in getting this resolved!

You are going to have to become very knowledgeable about insurance, denials and appeals in order to fight this.  They do automatically deny all claims and only cover it when the insurance commission forces them to do so - because it costs so much money under insurance.

I had to call and ask for a copy of the bariatric coverage from mine - they didn't even include it in the regular policy materials.  And study it.  Know it forwards and backwards.  Also call your state's insurance commissioner's office and ask them questions about when they step in to review an appeal and give a ruling.

It's a huge fight, long and drawn out.  The insurance company is trying to get you to just go away.  Keep at it, and you will find a way.  If you hit a dead end, and you have the money, call and get the help of a professional on this.

I started down this path and 4 months into the fight I realized I was fighting a major enemy - my insurance company.  And they were going to screw with me every way they could.  And I knew I was going to lose my job in another 8 months (and lose my insurance policy), so I started checking out Mexico as a self pay.  There are 2 very good surgeons down there - one was already mentioned.  I just happened to luck into a program here in California that cost me about the same.  But I was all set to buy my tickets to Mexico.  I was talking to both surgeons down there.

I had the 15K to throw at this (it was my life savings), so self pay was what I did.  Because playing the insurance games can take years, and I didn't have that kind of time (or patience) left.

 

Do  you have comorbidities? After my first denial I got letters from my cardiologist/sleep specialist showing I have sleep apnea....another from my obgyn showing I have pcos.... And a letter from a endocrinologist... And a primary care doc note. My appeal went through