insurance appeal?

ugh..I just can't seem to get things going my way lately and my DENIAL from my insurance company is just another piece on top of the pile. ..

In january when I was looking into WLS, I called my insurance company and they sent a packet of all requirements before I would be approved for surgery. This included 6 months of dietary supervision, psych eval and the other usual things. In fact, my list was so small that the insurance lady for dr. stewarts office (leah, at the time), remarked that the info sent to them by my insurance was only a few pages and most people have 20+ pages of info sent. This made me feel good..I did not have a lot of hoops to jump through. I basically just needed my psych eval, 6 months of visits and then the usual dr. stewart requirements like bloodwork, endoscopy, etc.

I finished my 6 months of visits on July 28th and sent them out to insurance. I got a call yesterday that UHC had denied me and they are claiming that I am not allowed to have had my dietary visits with Dr. Stewarts office. They say I could have had them anyyyywheereeee else BUT his office. And they say I was told this.. None of the paperwork that dr. stewart has from the insurance company say anything about my visits being allowed or not allowed at my WLS's office. I won't erase what I already wrote..well, simply because I already wrote it and was wrong. Read my post below for an update :(

Dr. Stewart had a personal phone call with someone at the insurance company today and they refused to budge. I am kind of lost at this point. Do I call and threaten a lawsuit and scream to high heaven? Why why why would I have wasted hundreds of dollars and time going for visits that did not count. My PCP is literally next door to Dr. S's..but I dont ever remember reading or being told it had to be with someone else.

Where do I go from here?? I am not going to go down without a fight. I have done my 6 months..I am not doing it again!!

thanks in advance for reading my rant and any advice you may have./ read a few posts below for an update. :(

-casey

Hi Case, so sorry to hear you are getting the run around.  Do you have in your hands the policy document which defines your bariatric surgery coverage?

If you do, this requirement would likely be spelled out right in there.  If you don't, then call your insurance company and ask them to walk you through getting it on the web.   You should be able to see it for yourself.  Ask them to show you where it says that.

Here is a general United Healthcare Policy:
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII /UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf /Tools%20and%20Resources/Policies%20and%20Protocols/Medical% 20Policies/Medical%20Policies/Bariatric_Surgery.pdf

It does not state that requirement here.  However it does state:  "When deciding coverage, the enrollee specific document must be referenced."   


That's the only way you'll know for certain.

Calendar Girl-

Is this UHC's generic WLS policy or someone's policy specifically.  I want to use it for my case with the surgeon's office, but I don't want to use it until I know what it is exactly, who the document is for.  I have UHC, that's why I'm asking.  The surgeon's office insists I have to follow UHC's rules for WLS when I was led to believe that I follow the UHC policy that my company paid for, that I signed up for, as in: "In the event of a conflict, the enrollee's specific benefit document supersedes
this medical policy."

Me being the enrollee.

INSTRUCTIONS FOR USE
This Medical policy provides assistance in interpreting UnitedHealthcare benefit plans. When
deciding coverage, the enrollee specific document must be referenced. The terms of an
enrollee's document (e.g., Certificate of Coverage (**** or Summary Plan Description (SPD))
may differ greatly. In the event of a conflict, the enrollee's specific benefit document supersedes
this medical policy. All reviewers must first identify enrollee eligibility, any federal or state
regulatory requirements and the plan benefit coverage prior to use of this Medical Policy. Other
Policies and Coverage Determination Guidelines may apply. UnitedHealthcare reserves the right,
in its sole discretion, to modify its Policies and Guidelines as necessary. This Medical Policy is
provided for informational purposes. It does not constitute medical advice.

Hi Imissthe80s,

The site where this document is located states it is a resource for physicians and other health care professionals.   So it appears to be the UHC generic policy. 

Yes, you would have to follow the UHC policy that your company paid for, that's why you should call the number on your enrollee card, give the agent your group number, etc., and let them direct you to your specific policy on the web.  You have a right to it and you should be able to see for yourself  the requirements they are asking you to meet.

Thanks, Calendar Girl! Unfortunately, the WLS policy is not on the web, I've asked and was told to get it through my HR.  I'll do that, although I had UHC fax the WLS criteria to me a couple months ago.  I need to get a hard copy as well, I suppose.

One more tactic to dissuade and delay...

That's insane and I'd be super p*ssed off! I have UHC and they didn't require a diet or psych eval, but possibly a different policy is the reason there. I'd call and demand they show you where in writing they told you (or in your policy)  that it was stated it had to be a different Dr. That's seriously the dumbest thing I've ever heard! 

I hope you can get it straightened out!

Oh my god I am so screwed. I feel like the biggest idiot in the world. Just went over original requirements from insurance company with a fine tooth comb and in my paperwork, it says

"must participate in at least one physician supported weight loss program documented by a physician who does not perform weight loss surgery, lasting for a minimum of 6 cumulative months and occuring within two years prior to surgery"

I am so angry with myself..and while I love Dr. Stewarts office..I am angry at Leah, the old insurance person who should have caught this when she supposedly went over my documents. I have wasted 6 months of my life, my time and my money. I don't even know what to say. I am smarter than this..but I just trusted someone else and didn't do my own research.

Would it even be worth it to try and appeal?? I am so angry with myself right now.  I have every other requirement met and done..I have met with a nutritionist in that office every month..not with dr. stewart, but someone in the office which I guess they consider dr. stewart since they are the same physician.

It is ridiculous.....but they got you.  I don't think an appeal would work - you can always try but like you said....it is in the paperwork.

Probably not what you want to hear but if you really want this surgery.....you will have to suck it up and do another six months with your primary doc.  If that is your choice, call your insurance and tell them you will play by their dumbass rules and do another six months and start it immediately so august counts.

 Did your PCP document it while you were going through it?