Denial by Insurance - Please Help !

I need some help! In December 06 I was told by Deion at UHC that with review of clinical documentation deeming my surgery was a medical necessity that I could be covered. In Jan 07 my surgery coordinator called UHC and spoke with Mark S. who also said the same thing Deion said - with review of clinical documentation deeming my surgery was a medical necessity I could be covered. So starts all the tests that UHC requires for the approval process. All 43 pages of clinical documentation was sent to UHC on April 3. On April 13 I called UHC and was told I was denied, but no one could tell me why. My surgical coordinator called me on April 17 and told me the reason was that my employer had not purchased the weight loss surgery rider. She suggested that I go to the human resources director which I did, she had no idea what a weight loss surgery rider was so she in turn called our insurance agent who again had not idea what "rider" they were talking about. In the meantime I got the denial and an email from our insurance agent stating that they do not cover any kind of weight loss surgery whether it is deemed a medical necessity or not. I feel like I should be able to appeal this as the reason I am overweight is from a disease called PCOS not that I just overeat. Does anyone have any suggestions? Is there a loop-hole I can get this approved thru?

From what I have read its almost impossible to get your insurance to cover WLS if the rider wasn't purchased and they have an exclusion. My husband had BCBS and there was an exclusion. So I had to find a job that covered it and that's what I did. You may be able to hire a lawyer. But of course even after you do that it's not a guarantee that they will be able to get it approved. Good luck!

I feel for you girl, I've fought my husband insurance (Cigna OAP) for 4 yrs. 2 appeal's and talked to John Oxiedian? and was told as long as thier insurance booklet stated no cover for any kind of weight loss surgery whether it is deemed a medical necessity or not, there's nothing I could do. Now, I'm on disabilty due to health reasons, and trying to get the surgery with medicare. Insurance companies are stupid, if they paid the $30,000 yrs ago for the WLS, I wouldn't be almost @ the $100,000 amount now with my husband insurance. Never give up though...... Appeal your insurance if you can, keep all your ducumention. Good luck.....

Thanks for you response, The more I hear about UHC it seems the worse it gets! My company is set to renew in July and from what I understand they are going to be offered the rider but at a price of 60% of current rates, I doubt that they will take it! I am going to continue to fight this, not sure that I will get anywhere but I feel like I have taken 5 months out of my life based on UHC telling me this would be covered with review of clinical documentation. I work in insurance and know from my experience that if you tell someone they have coverage you have to stand behind your word- Obviously heath insurance is not ran that way. Again Thanks!

Good Luck!!! I had UHC also when I was first thinking of getting the surgery and I tried everything to make them pay for the surgery also but because there was no rider there was nothing I could do to make them. I even went so far to tell them how many customers they was gonna be losing and the money they could save on medications,physician visits and other necessary treatment for obese people. It still got me nowhere. I had to change from UHC to BCBS. Hope you have some luck.

Thanks for you response, The more I hear about UHC it seems the worse it gets! My company is set to renew in July and from what I understand they are going to be offered the rider but at a price of 60% of current rates, I doubt that they will take it! I am going to continue to fight this, not sure that I will get anywhere but I feel like I have taken 5 months out of my life based on UHC telling me this would be covered with review of clinical documentation. I work in insurance and know from my experience that if you tell someone they have coverage you have to stand behind your word- Obviously heath insurance is not ran that way. Again Thanks!