2010 UHC SHBP requirements

Any UHC SHBP 2010 WLS applicants out there - - -- I need your input please!

I have UHC SHBP; hypertension; bmi 40

I am currently into my third month of six month monitored dieting and group therapy.

I have been diagnosed with sleep apnea this week.  I have an appointment for another "sleepless night" to fit me for the cpap.

UHC bariatric nurse is telling me I have to have 16 or higher sleep apnea for it to count as a comorbidity.  At this time I do not know what my score is for the sleep apnea.

I have high cholesterol (tested July 09 and Jan 10), but because my doctor is monitoring and has not put me on meds, it is NOT allowable as a comorbidity - per UHC bariatric nurse.

My UHC nurse is Jackie Janus.  Do any of you have this same nurse for 2010?  Do any of you find that the 2010 comorbidity specifics are more rigid than those requirements in 2009?

I am in a catch 22 as I try to naviagate through six months of monitored dieting, but yet meet the 40 bmi for WLS insurance coverage.

THIS IS RIDICULOUS!!!  I can't even get a copy of the "summary plan description" for 2010 - - -  SHBP won't answer the phone and UHC says that SHBP is responsible for issuing it.  This is the document that tells the SPECIFIC  benefits for our WLS coverage, and we have been paying  premiums for this insurance since the beginning of the calendar year (Jan 2010)!!!

I am ready to make a call to the Ga Insurance Commissioner at this point!!!

Please give me your input and experiences with UHC - HRA calendar year 2010.

Andrea I have shbp Cigna, so I don't know how much help I can be.

The wls surgery require,requirements should be somewhere on the website.  Check the shbp micro-site to get the shbp requirements because they will be different from UHC normal requirements.

The requirement for approval if over 40 doesn't require co-morbidities if I am not mistaken.   You may have co0morbids that you are not aware of

PCOS, diabetes, hypertension, depression, back pain, edema or swelling, rashes from excess skin on belly or breast,   Your surgeon's offc will help you come up with something, so definitely don't stress about that.


As for the weight loss, my bmi was borderline to qualify for DS, so I tried not to lose those 6 months. They don't require you to lose, just that you go to the dr appts and have the weight, height, bmi, etc recorded.   Once they approve you you are free to lose as much as you want, so definitely hit the diet hard once you're approved to make yourself more fit for surgery.

 

Our plan is self funded, so the insurance commissioner does not regulate it; however, if enough people gripe to his office about it, I truly believe it makes a difference. After all he has the same insurance we do, since he is a state employee too right?


I'm kinda bummed nobody is responding to your post. Not sure what's going on with the GA forum. Seems like everybody got their surgeries and went ghost on us. 


Come on shbp veterans and lurkers. someone was there to support you through this mess last year. Time to play it forward.  
 

A 2009 UHC SHBP patient here, but according to the myuhc.com website, the comorbities requirements are the same.  

I agree with LaShelle.  If you are worried about dropping below 40 BMI, don't lose any weight until after approval.  They only want to see you go to the doctor and the doctor list your weight and the type of diet you are following at each visit.   

I also agree that you may have a comorbidity that you do not know about.  Have your surgeon or PCP help you out in that area.  When you go for the CPAP fitting ask them about your score. 

I am so sorry you are frustrated.  As I have told many, you will reap the rewards (many times over) for your patience. 

I am on the final month of the what is suppose to be the 6 /7 month diet. I have only lost 2 pounds since starting the diet because I really don't have any comobidities and have tried to maintain my weight more than lose it for right now anyway. But, I just recently found out that I have osteoarthrittis in my hip so i'm hoping that it will help me to be approved. My bariatric nurse is Jill Stagg and she has been great during this process.

When the new year came in I called her to see if anything changed as far as benefits goes she said that it didn't  but I'm not sure about the comobidities part. However; it would seem to reason if your bmi is 40 and you have some comobidities you have a good chance of being approved but I realize that we are talking about insurance. I have to call her in a day or so just to check in because soon it will be time to start trying for approval for me and if I find out anything new  I'll let you know. Hang in there the time really flies by I can't believe all of the preapproval stuff is almost over.

Mindy

Thanks for the replies.  I think I must have a strict, strict, "by the books" bariatric nurse.  My sleep study shows a sleep apnea AHI level 7 and my nurse said it must be 16 or more to be counted as a comorbidity.  I'm just gonna try to stick with no going below the 40 bmi, to be safe, and try to LEARN from my dietician, new eating habits, weighing food, counting protein and carbs for help AFTER the surgery.

Please keep me informed of how your journey turns out...

Thanks for taking the time to respond....

Andrea

Mindy -

I forgot to ask.....what insurance do you have?  I hope all goes well over the next month or so and you get approval without any snags...

Sincerely,
Andrea

Thanks for the well wishes, I have  United Health Care Hra. I will keep you all posted I went for the cardic clearence today. I have to go back on the 5th to do the stress test. wish me luck on that one.

Andrea, I also have Shbp UHC.  And I have Jackeie Janus as my nurse cooridinator as well.  I was told that you are not required to loose any weight on the 6 months supervised diet.  If you are at the 40 BMI, you do not need any comorbidities.  Unfortunately I am over 44 and do have the comorbidities.  I would rather not have them,  though.  Do you have acces to myuhc website.  The summary plan description is posted on there if you can figure out how to get to it.  Here is an excerpt that pertains to the gastric sleeve:

Bariatric Resource Services (BRS)   Gastric Sleeve Procedure is covered if all of the outlined criteria is met.

SHBP will provide an obesity surgery benefit beginning 1/1/09 for the HRA and HDHP plans only (and only applies when SHBP coverage is primary). All authorization information and enrollment for bariatric surgery must be initiated through OptumHealth’s Bariatric Resource Services. Covered participants seeking coverage for bariatric surgery should notify Bariatric Resource Services after 1/1/2009 when the program and benefit becomes effective.  After 1/1/2009, Customer Care may transfer the caller to Bariatric Resource Services to speak with a bariatric nurse consultant.   Bariatric Resource Services is a program administered by UnitedHealthcare and its affiliates. For obesity surgery services to be considered Covered Health Services under the BRS program, you must contact Bariatric Resource Services and speak with a nurse consultant prior to receiving services. Bariatric Resource Services will be available for these discussions after 1/1/2009.   Specific Benefit Design and Limitations   ·        Coverage of Bariatric Surgery is limited to ONE bariatric surgical procedure per lifetime. This lifetime limit also applies to any member who has undergone baraiatric surgery in the past while covered under a previously offered SHBP option. ·        Applies to Active and Retirees ·        Members and dependents over the age of 18 and physically mature ·        Deductibles and Out of pocket expenses apply to all services associated with the procedure ·        Lap Band Maintenance is covered.   Pre-Surgical Requirements   You must meet all of the requirements below BEFORE the benefit is approved.  You must contact Bariatric Resource Services and speak with a nurse consultant prior to beginning pre-surgical requirements:    Ø      You have a minimum Body Mass Index (BMI) of 40, or 35 with at least 2 co-morbid conditions Ø      You are over the age of 18 and physically mature Ø      Weight reduction services are covered ONLY after you contact UHC's BRS program and receive PRIOR approval. Weight reduction services are covered only at approved BRS COE and by an approved BRS COE surgeon who is approved by the BRS COE program. Ø      You must complete the myuhc.com health risk assessment Ø      You must successfully complete a six month physician supervised weight loss program Ø      You must successfully complete pre-surgical psychological evaluation and outpatient counseling for six months Ø      You must agree to comply with all post-surgical program follow-ups as suggested by the Bariatric Resource Services nurse consultant (post-surgical nutritional counseling, post-surgical outpatient behavioral counseling)   If the caller needs additional information on the program and clinical requirements, the Customer Care Professional can send a message via the PEACH mailbox, including the caller’s call back information, and the caller can expect a return call.   They can access the BRS Service Centers of Excellence Programs at 1-888-936-7246.

Hope this helps.

2muchfluff -

Thanks for the info.  It is nice to hear from someone that has the same insurance AND  the same bariatric nurse.  At what stage are you in the program?  I am hoping to finish up the six months of "dieting" and therapy in July 2010 and then submit for approval and a surgery date.  Definitely this is the first time I have ever considered "WANTING' co-morbidities- - - - - - and maybe I am just being too cautious with the whole thing.  I just don't trust insurance and don't want to get caught in a catch 22..............lose weight on the 6 month diet, drop below 40 bmi, and then not meet the bmi requirements and only have one comorbidity that would count with a bmi below 40.  It turns out even though I have the sleep apnea, it is an AHI level of 7 and a comorbidity for sleep apnea only counts with an AHI level of 16 (according to Jackie Janus).  Please stay in touch and let me know how your journey has gone so far and at what stage you are in the process.

Thanks again for your response!


Andrea

You are welcome, Andrea!  I am really just getting started.  I already started the weight loss part, but don't have my first consult with the counselor till 4/7, so my 6 month period really won't start until then.  What is an AHI level, anyway?  I have sleep apnea,also and am on a CPAP, but I never heard of that.   I don't blame you for being cautious.  Insurance companies are famous for telling you one thing and then denying they ever would have told you that.  I also have high BP, which is under control on meds, so that is my other unwanted comorbidity.  I am also prediabetic, so that is one of the main factors that makes me want to do this surgery.  My hubby is diabetic, among other things, and I do not want that life !  I want to regain my health, while I still have a chance.  What surgery are you considering?  I am looking to get the sleeve.  Hope things go well for you, and keep in touch throughout!