Appeal update

Well my appeal was filed last week and I received the decision yesterday. Here's what was said: " Uphold denial. Although this patient clearly has a very high BMI and is at risk for future complications of disease due to her obesity, presently pt does not have any co-morbid conditions poorly controlled with conservative management. In addition pt has only been enrolled for two months in a physician supervised wt loss program under the supervision of Dr Graniero. During the time pt has had a wt loss of 28 lbs. If after six months of supervised wt loss management she fails to maintain a reasonable wt loss, she will be reconsidered for bariatric surgery." AND I SAY WHAT A CROCK !!!! I guess I have to be on my death bed before United Healthcare would approve me. So now I have to file for a fair hearing. Prior to the fair hearing I am having a sleep study done. This is something I should have had before filing but I didn't know that my snoring was that bad. According to my husband I breath very fast in my sleep and snore on occasion. Well if I'm diagnosed w/ sleep apnea then I'll have the co-morbidity UHC is looking for. Plan 2: If they don't help me then in May I am changing insurance companies and I can start new with them. Then I can tell UHC Well enough about this ness. I have to get my son to bed. I'll keep you all posted. Barb

Barb I'm sorry you are going through this non-sense, and I really do know what you are going through, I was denied on 2 appeals and have been in the loop for over a year, I did have surgery on a technicality, My insurance company also wanted the six month supervised diet and most to require it..... after your six month and you are not able to get approve than there is a lawyer here at oh that might be able to take your case and assist in getting you approved..... Barb hang in there I do believe that you will have surgery when the time is right, so please please please hang in there and never give up..... Christine

Hi Barb. Im so sorry to hear about this. I am very very shocked about United Healthcare. They are supposed to be one of the best Insurance companies that cover WLS. I have oxford, which just recently merged with united healthcare and they DO NOT require a 6 month supervised diet. I was approved in under a week. I have never heard of that with UHC. Does it say specifically in your coverage book that you have to follow a 6 month diet. Please give them a call and let them know that you do not need a 6 month diet first. Let me know what happens. Good Luck!

Hi Barb, I know this must be so frustrating for you. I know someone who has worked for the health insurance industry for a long time. We had a long talk the other day. I got a real education. A lot of people blame their health insurance companies when there are denials or problems with coverage. Actually, the insurance company is only the "enforcer" for the employer who purchases the insurance. For instance. My husband works for Harden Furniture. We have RMSCO insurance. RMSCO only manages the claims, but Harden tells the company what they want insured and the rules for which to go by. When a company contracts with an insurance company they purchase a policy for their employees based on what they want and don't want covered, and how much they want to pay for insurance coverage. In cases of self-funded insunce such as RMSCO, the employer could actually overturn a denial. The insurance company is obligated to enforce this. Certain companies have corporate medical policies that are across the board with every single policy they have regardless of employer, especially when it comes to weighloss surgery, due to the cost of the surgery. Some of the statistics that the insurance industry has used in the "six month weight loss" thing, is that some patients lose so much weight in six months they decide not to do the surgery. I do take issue with this however, because how many of us have lost weight only to regain it? That's why we are in this position to begin with. Be careful switching insurance companies right away as some companies are excluding weightloss surgery all together and because this is not a state mandated surgical procedure (at least I don't think NYS has mandated it yet), insurance companies do not have to cover it. I know this is very discouraging. Please file for your hearing. Work with your surgeon and your physician. Have you written a letter to tell your insurance company (and or employer) how your obesity affects your everyday life? I wish you all the very best. Debra