help on insurance

can anyone please help me. my daughter in law lives in ga and has united health care choice with the state of ga.the insurance co tells her that wls is not a covered procedure. my son works with state prison system. does any of you have this insurance and have you had wls and did you get it to cover? any help would be greatly appreciated. thanks louise

Hi Louise, I also work for the State of GA. and have UHC. I am in the process of trying to get approval for my surgery. I called UHC and was told this is not a covered procedure but when I told them it is definitely medically necessary I was told that it would probably be turned down but I can appeal. I haven't been turned down yet but plan to appeal when I get my denial. I think that UHC will have to cover it if there is verifiable documentation that this is medically necessary. My problem is, I have tried to get a "Certificate of Coverage" from UHC showing what is covered and what isn't but they won't send it to me. Keep in touch with me and I will keep you posted on the progress of my claim. Judy

Judy, Will you keep me psoted on the progress of your claim as well. Thanks.

Judy, thank you so much for the info. My daughter in law has done what your doing now and she has already been denied. She has submitted 2 letters from 2 different doctors stating that with her medical problems she would be an ideal candidate for wls. Being a nurse and not working I have taken this over to try to get her approved. She is sending me all her medical records and the letters and all corspondence from the insurance company. I had wls 17 months ago and have done wonderful I lost 100#. I had united health care with my husbands company and had no problems with them. They told me on the phone it was covered and the doctore submitted the paperwork and was approved in less than 2 wks. I will keep you posted. We need to write the congressman and rep from each state and encourage them to help get this approved. They are state employees like the rest of you all and if it was them they would make sure it was coverd. thanks a lot. Louise

I'm a state employee also. I recently asked the same question. I called UHC and they told me I can submit a request to Care Coordination. I have coworkers that have had this surgery, but they are not close enough to ask "Which insurance did you have?" One woman is single so I know her only insurance has to be the state insurance. She is denying having weight loss surgery though, but we all know she had it, she is losing weight too rapidly and isn't crying about it so she's not sick. People are strange or rather I should say "I respect her privacy." When I received a packet from Dr. Champion's office, the preliminary paperwork stated "state merit" does not cover this surgery. I wasn't sure if that meant the state funded option insurance or all Georgia state merit insurance including the HMO's. I plan to go through the process, appeals and all and see where I get. Best to you! Rhonda

I have cigna hmo and am a school district employee. I at first did have state merit and they said no way no how would they cover surgery. Then during open enrollment i spoke with cigna who informed me they would cover it with proper authorizations. Well now I am trying to get it approved and they say they won't cover in 2005. I said okay but I am in the middle of my plan year. Go figure They paid for all the consults and other requirements they wanted. Well I have since spoken with state merit who told me that "it clearly states in the bylaws we won't pay for gastric bypass." After some research I found that the state merit summary of benefits does say that but it is for PPO, PPO Choice, and Indemnity. I already knew they wouldn't pay that is why i went HMO. Well under the HMO it said to see the Health plan benefit options for restrictions. I can find no where it states that the HMO will not cover it. I have not yet gotten a denial but am waiting. I will continue to push for it. Good luck. Nalani

I too work for the state of ga. I first had state merit and they said no way no how would they pay for it. So then during open enrollment after talking with cigna and them saying that you must meet their requirements but that they would pay for it i switched. Well I switched to cigna and have done all the requirements which they paid for and Dr. Duncan is supposed to be sending off for approval. I am patiently waiting. But anyway Cigna now says that they are not covering in 2005. Well my point is that my policy is still in mid-year. It does not renew until July1, 2005. They still say they are going to deny. Well i called state merit and a gentleman very abrubtly told me "it clearly states in the bylaws that state merit will not cover WLS." Well i got a copy of the summary of benefits book and it does say that state merit PPO, PPO choice, and Indemnity plans will not cover. As for HMO it says to see the Health plan decision guide to see the restrictions. Well it says nowhere that the HMO will not cover it. I have been told if depends if your company is paying extra for the rider. Well state merit is not but like i told cigna neither them nor my employer can change my plan midyear without informing me. This has begun a long ordeal for me but i plan to keep on pushing. I have learned also to document everything. Good luck. Nalani

Nalani and Rhonda, please see the above post. Thanks for the info. I will keep you all posted what I find out about the state of Ga insurance. Louise

Hi Louise, I agree about writing the congressmen regarding UHC turning down our wls. Most likely, they don't have UHC though. The state offers a lot of different insurance plans for state employees throughout the state depending on where you live and what department of the state government you work in. However, whichever insurance carrier they have, we pay a lot of money for coverage and I feel they should cover my surgery. I will contact my congressman regarding this and hope you all will do the same. United we stand!