Denial letter from UHC said...

OK - Got my DENIAL letter in the mail today.  Basicaly in quotes it says, "Sugical and non- surgical treatment of obesity except for surgical treatment of morbid obesity" Bariatric surgery is covered for (a) morbid obesity and (b) severe obesity with severe obesity-related co-moridities. Absent documentation of either of these clinical cir****ances, services are excluded from coverage. So, they are saying that I'm not fat enough or sick enough! That's the impression I'm getting from the letter as stated above. My question is what "official" BMI calculation do they use? Is there a standard? Do I have a leg to stand on for an appeal? I'm 5' 5" and 226 = BMI of 37? Any advice would be appreciated!

Wendy, Did you make complaints of joint problems, hips, feet, back aches, knees?  Your BMI is 37.6...have you had shortness of breath?  You just need them to send it back with documentation of some kind of physical problem.  How does your weight harm you now? I would appeal....for sure. Manya

My surgeon wrote about joint pain (knees) and also on doc. sent to UHC from PCP it showed a visit for knee pain and even did x-rays! I'm borderline hypertensive so I think I'm going to go back to PCP and start on some BP meds. I am also going to go for a sleep study, maybe I have apnea? I have woke up many times during the night gasping for air - I always just thought maybe I was dreaming that I forgot to breath? Strange! Yes, I am! I will definitely APPEAL! I think I'll just try to get a little more ammo first.

Wendy, It does sound like they are looking for co-morbidities. I think all you need is to send in documentation of that. You are on the right track with the sleep study. How about hip, joint, knee pain, high cholesterol, etc? I bet a letter from your PCP about the hypertension, sleep study, shortness of breath and all the joint pain and you will be on your way. The only thing I would check on is there is sometimes a time limit on appeal. I think alot of people get approved the 2nd time around. I'm so sorry and I know you must be mad as H*&% but you will win this. I just know it! Hugs for you,  Jennifer

Jennifer- My denial letter said 180 days but made no mention as to how many times I can apeal?

Wendy, APPEAL!  APPEAL!  APPEAL!

Yes, it does sound as though they are just asking for documentation of co-morbidity factors.  The rule of thumb for the insurance companies seems to be a BMI of 40 minimum without co-morbidity factors.  Under 40 and they want documented co-morbidity to justify the surgery.  What about GERD (reflux)?  Get your ducks in a row and you should have no problem with your appeal. Sorry for your disappointment, nonetheless. Suzanne

I have documented GERD that was submitted - guess that doesn count. Have no fear - I will come up with something!

Yes, good.  Are you being treated for the GERD?  I take aciphex daily for it.  With respect to sleep apnea, I suffered from that for YEARS and never knew it.  I have been sleeping with a CPAP machine for almost 3 years now.  HBP meds.  Angina.  Arthritis/tendonitis/bad knees and hips.  All being treated.  Seems like every time I walked into my doc's office, I was being handed another Rx!  When he announced to me that my blood sugar was rising, that is when I said enough!  I think the deal is with the insurance companies, when the surgery is a cheaper alternative for them than treatment for you assorted illnesses, they view WLS more favorably.  Appeal!

Yes, I have been taking various GERD med's for years. I've tried them all including aciphex. Currently, I'm taking Nexium 40mg.