Insurence change requirements downward? Have you heard of this?

Insurance Requirements

My insurance is United Healthcare, and when I called them they said they cover WLS with BMI 40 and over. But I have BMI of 38 with diabetes. The insurance councilor was evasive as to weather or not they cover BMI 38 with diabetes, and instead directed me to have the surgeon submit a claim for coverage.

Well, I addressed this on these forums and someone found information on United Healthcare circa 2007, and this is what the requirements were then:

o BMI 40 or greater OR BMI 35-39.9 with at least one of the following commodities such as cardiovascular disease including stroke, myocardial infarction, stable or unstable angina pectoris, coronary artery bypass or other procedures, hyperlipidemia uncontrolled by pharmacotherapy, type 2 diabetes uncontrolled by pharmacotherapy, hypertension uncontrolled by pharmacotherapy, or moderate to severe sleep apnea with a respiratory disturbance index (RDI) of 16 to 30 or apnea-hypopnea index (AHI) >30 as documented through the completion of a laboratory based polysomnography o Previous failed attempts at losing weight using more conservative therapies o PCP Letter o Diagnosed as Morbidly Obese for the past 5 years (documented in Medical Records) o 18 years of age o Psychological evaluation   o Gastric bypass, BPD/DS and Lap-band procedures are covered    


Well, when I went to the Weight Loss Center today the nurse said that United Healthcare only requires 5 year documented history. When I probed more, she said basically they just need a list of my weight going back as far as I can to show obesity and when I had diabetes.  She said that so long as I have a BMI over 35 with diabetes then according to what United Healthcare gave her, this was their only requirements.

I guess my question is Has anyone heard of insurance that only requires this little? And why would the requirements drop so significantly?

I have Aetna. Aetna's qualification is 40 BMI or 35 BMI with 2 comorbidities (high blood pressure, high cholesterol, diabetes, joint disorder, acid reflux). I think their qualifications read something like a 5 year documented history of weight issues. The real problem with this is that they want office notes that show counseling and discussions at the office visits. Most doctors do not do that. The alternative in their policy was to undergo a 3 month documented process of doctor visits where you discussed diet and exercise.  I suspect if you are a BMI of 38 and have the number of comorbitiies your policy specifies that you will qualify. The best thing to do is ask for their clinical bulletin on weight loss surgery. Aetna had one. I have been told that most major insurers have such a document. It spells it all out.

Thanks alot ohbearly! I'm going to call them for that tomorrow then. I half feel that.... if I ask them questions then for some reason they will document my policy in an attempt to find reasons to decline coverage.

Sorta like how auto insurence companies try to find ways out of coverage when they try and trick you when you call in to ask questions. Do you know what I mean?

Yes, I have Blue Shield PPO and I qualified for surgery with a BMI of 41 and no comorbidities. Insurance approved surgery within 5 days after surgeon submitted for authorization. I have now lost 64 lbs. HOORAY!

 I truly wish you the best of luck!

I have Humna PPO I talked to them on Tuesday, said it would be in 48 hours would get a return call,  call them a few minutes ago now they said it would be next week before I found out what is covered and what isn't. I have Sleep Apena and II diabetes as well. My BMI is at 37.3 percent.