AZ State Employees-UHC Criteria

Hello everyone! I've been lurking here for a while but I have my initial consultation on Thursday, so thought it was time to start posting. After many phone calls, I finally got the following criteria which apply to State of Arizona employees with United HealthCare EPO. If anyone knows anything about the UCLA study mentioned, please let me know - I haven't been able to find anything! Hope this helps! -Gabrielle ~~~~~~~~~~~~~~~~~~~~~~~ Gastric Bypass Services Guidelines: Demonstrate 10% weight loss prior to auth to demonstrate commitment, per recent UCLA study. Documentation of 6 consecutive months of physician-supervised weight loss program (including monthly weigh-ins, nutritional analysis, education and at least monthly clinical encounters with a health professional) documented by a physician who does not perform weight loss surgery, within the past year. The weight loss program should include all of the following physician-directed components: -Dietary therapy & Increased physical activity -Behavioral therapy to reinforce dietary therapy and increased physical activity -Consideration of pharmacotherapy with FDA-approved weight loss drugs. *Diet programs/plans alone, such as Weigh****chers®, Jenny Craig® or similar plans, are not considered physician-directed wt loss programs. Physician-directed programs consisting exclusively of pharmacological management are also not considered physician-directed programs. Documentation from the medical record indicating that consistent reasonable efforts have been made by a physician to manage the comorbidities using standard medical protocols. Inadequate treatment of a comorbid condition should not be used as an indication for gastric bypass surgery in those patients with BMI's between 35 and 39.9. Note: All patients should undergo careful selection after evaluation by a multidisciplinary team including documented medical, psychological & nutritional evaluation. A pt should be acquainted with nutritional needs & the physiologic & behavioral changes necessitated by the surgery, as documented by a physician or healthcare professional. In Network only: Network vendors to scrutinize providers Criteria: 100# overweight (ideal body and/or twice ideal body weight) with a BMI of 40 with clinically serious medical condition of obesity: life threatening cardio-pulmonary problems such as:hypoventilation, severe sleep apnea, Pickwickian syndrome and obese related cardiomyopathy, clinically unmanageable diabetes, hypertension, life threatening cardiomyopathy problems, coronary artery disease, obesity related pulmonary hypertension. Must include ALL of the following: Psychiatric assessment and approval Medical assessment and approval Nutritional Counseling Exercise Counseling Psychological Counseling (licensed practitioner) Support Group Meetings Age: must be between 18 and 65 years of age Primary Care Physician (PCP): each candidate must have a primary care physician, a physician who practices in the community in which the prospective patient resides. That PCP must perform a physical examination on the prospective candidate for weight loss surgery, and provide written verification of (1) the examination and findings; (2) that the prospective candidate is medically stable and able to withstand surgery, and (3) agree to provide follow-up care after the surgery. Psychological Preparation: If the prospective candidate is under the care of a licensed mental health prof., that prof. must provide written verification that (1) he/she is treating the prospective candidate; (2) agreement that wt loss surgery is appropriate for the prospective candidate. Each prospective candidate must pass standard psychological screening test, (such as MMPI). The above guidelines are subject to change based on new clinical evidence of adverse outcomes.

I think I would post this on the main message board to see if you can find out about the UCLA study, but my hunch is that it's basically another b.s. roadblock designed to avoid having to pay out for the surgery. If the morbidly obese were any good at losing 10% of their body weight, we wouldn't have to have this surgery in the first place! This kind of thing always comes out seeming so absurd if you compare this surgery with any other lifesaving one - like cardiac by-pass for instance. Imagine if a man were expected to get his cholesterol numbers down or his weight down before having cardiac surgery! No way! There'd be a riot against the insurance companies! Guess that's the big difference between men's diseases and predominantly women's diseases! It's considered perfectly OK to put up barriers and hope that we'll die before we ever get the coverage. What crap! - Stephanie J

Hi Stephanie! I tried posting it on the main board, but so far nobody seems to have heard of the study. I have emailed United HealthCare to see if they can give me more info on it, but I agree, it does seem like a bunch of bull! Thanks! Gabrielle

Gabrielle, here's the link to the UCLA website: uclabariatrics.mednet.ucla.edu/ (put http://www. before it for link to work) I had my surgery at UCLA in Feb 04. Yes, they do require a minimum of 10% weight loss as does Pacific Barriatrics in San Diego. It is a fairly common requirement now. My high wt was 305. I had documented weight loss from 1/03 to 6/03 of 26 lbs thru weigh****chers. My surgeon still asked for an additional 20 lbs before he would scheduled my surgery. So I had to lose 46 lbs (over 10%). At the time I felt it was unfair BUT I knew it was the only way my surgery was going to happen. Did it add some stress, yes. But I got an additional 24 lbs off by doing high protein/low carb. Was the weight loss before surgery worthwhile ... absolutely!!!! At 51 years old I bounced back immediately from the open RNY. Surgery on Weds, home on Saturday. Saturday night I was out socializing and Sunday out shopping. The high protein diet helped in healing process, aided me in losing weight, help defat my liver prior to surgery. The liver is rigid if fatty and has to be moved over to get to stomach during surgery. A defatted liver is more flexible. I was under the old program at UCLA. There new one (stated just before my surgery) requires mandatory classes, weight loss, etc. They also seem to have a better follow-up program. With my program there I only saw the surgeon once after surgery and the dietitian twice. Lots of positives about the new program. I know for me the weight loss and exercise ahead of time made a huge difference in my recovery. I haven't had any complications at all and feel wonderful. I lost 50 lbs before surgery, 70 since for a total of 120 lbs. I have 60 more lbs to go. Wishing you the best. Mary (new AZ transplant)

Hi Mary, Thanks for the link. I've looked all over the site but I've never been able to find anything about this study that United HealthCare is citing. There seems to be a lot of conflicting information about pre-op weight loss and the reasons for it. Even the California Department of Managed Health Care has a review out that says it's unnecessary. I'm glad that losing weight pre-op helped you feel better faster. I've started a program that Scottsdale Bariatrics offers specifically to fulfill requirements like these - I know that regardless of what I think about this, UHC can dictate their requirements and if I want them to pay for the surgery, I have to toe the line. Congratulations on your weight loss! Gabrielle (I'm a new AZ transplant too... from VA!)

Gabrielle, There are different views on whether weight loss ahead of time is necessary or not. UCLA, PB in San Diego, and Kaiser all require weight loss now before surgery. Since those were my 3 choices (I had Kaiser insurance and they paid for me to go to UCLA or PB) I had no choice but to lose weight. Back in 89 I had my gall bladder out. I was much younger then and weighed much less than my high weight. I think the RNY is a much more invasive surgery than the gall bladder surgery. It took me weeks to recover in 89 and feel better --- I had no complications from that surgery either. The RNY I bounced back immediately. The only difference was the high protein diet with weight loss and exercise before surgery. The advance loss and exercise got me in a routine too that is so important after surgery. I Used protein drinks or bars at least one meal a day, sometimes two pre surgery. Wishing you the best in your journey. Mary

Good luck with your attempts at getting the surgery approved. I too work for the State, but had the surgery approved by Cigna right before we switched. I was jerked around by Cigna for so long that I swear the only reason it got approved was because they figured out that they didn't have to pay for it - UHC would. I'm glad to hear that at least they're covering it - even if you have to jump through a lot more hoops than I did. I had heard that they weren't going to offer it at all, so at least take comfort in that. Good Luck, and keep us informed!