Revision under UHC

Neenakerr
on 3/13/15 11:50 am

Hello.  I am new to this forum and this is my first post.

i have several questions and hopefully someone will be able to provide me with some information in reference to a revision.  

My scenario:  

i had the Lap Band (the "band"), and it was removed in 6/2014.  The removal of the band was due to complications with reflux (GERDS), regurgitation, etc.  At the time of my removal the surgeon's office had requested the removal without revision to another procedure because they stated that my insurance would not approve a revision to gastric bypass, only a revision to remove the band.  Unfortunately, they had 2 UHC policies on file and only checked the one policy.  The policy that approved the removal of the band was my husbands policy and that was a secondary insurance.  The primary insurance under my employer was not verified.  I spoke to the case manager at my surgeon's office and she confirmed that there was in fact a miscommunication with my insurance and policies.  

In October 2014, I reached out to my OPTUM nurse through Bariatric Resources through my primary insurance that does cover WLS if all the requirements are met.  1. 6 month consecutive diet through my PCP or nutritionist, 2. Psych Evaluation, which was completed and approved by a psychologist, 3. BMI of 40+ w/o co-morbidities, or BMI of 35+ With at least 1 co-morbidisity, 4. Be at least 18 yrs or older.  All os which I have met and completed.  The nurse and I also discussed the miscommunication the surgeons office had with my insurance policies.

Considering the confusion with my insurance policies, it has now been verified that my husbands policy doesn't cover WLS, but my primary insurance does.  

Under my primary UHC Choice Plus policy, I am only allowed 1 wls surgery per lifetime under my insurance plan.  My question to you is if my band surgery that was performed in 2006 under CIGNA still apply to this rule if I request a revision to gastric bypass now under my primary UHC plan since it is a different insurance company, policy and plan?

Do you think that since UHC removed my band last 6/14 that they would consider that revision the 1 surgery per lifetime revision even though it was a different UHC policy under my husband's UHC plan that approved the revision to remove the band?  I know this is confusing.  

According to my primary UHC policy they don't cover revisions which was explained to me by my surgeons office.  So if I submit my new paper work through my primary insurance it will be like a new procedure again.  This whole process has been such a headache.  I know my surgeons office had a miscommunication with my insurance policies, but now I am worried I won't get approved due to the 1 surgery per life time clause in my policy.  I have to wait 2 to 4 weeks before I'll know if I am approved.  

I wish they could have just approved the revision to gastric bypass at the time of the removal of the Lap Band.  So here I am now almost a year later trying to get approved for the gastric procedure because my  UHC insurance won't approve it as a revision.   Has anyone else's insurance denied them a revision to a secondary procedure at the time of a removal of the Lap Band?  

Has anyone's insurance denied them any wls procedure as a result of the 1 surgery per lifetime after the fact? 

Has anyone else experienced anything similar?  

Any help or information would be greatly appreciated. 

 

Valerie G.
on 3/14/15 12:07 am - Northwest Mountains, GA

From those who have come across this - I've heard that it doesn't matter who you had the first procedure with, that the rule still applies.  That being said, though, it doesn't hurt to comb through their policies and give them a call for clarification.

Valerie
DS 2005

There is room on this earth for all of God's creatures..
next to the mashed potatoes

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