BMI of 40....OR....BMI of 35 with Co-Morbidities....

I recently received a denial for the Lap Band procedure by UHC EPO which is a self-funded plan through my employer.   My BMI is 35.6 with Co-morbs of Type II Diabetes and hypertension.  I am totally confused as to why they denied me stating that my BMI is not at least 40 when the policy clearly states BMI of 40 OR BMI of 35 with Co-morbs.  HELLO!  Why are they not looking past the BMI of 40 requirement.  UUGGHH, so frustrating!  I have my appeal letter written and ready to go.  I just thought I'd ask if anyone else had this experience.  I think the ins. co. is just trying to get out of covering the surgery.

I don't have your same insurance, but BCBS of Alabama lists only the following as co-morbid conditions: Uncontrolled hypertension (meaning even optimal medication therapy is not controlling it), diabetes (you got that one), cardiovascular disease, pulmonary hypertension, or severe obstructive sleep apnea.   Seems like you would be accepted due to your diabetes.  Are you sure that your employer doesn't have an exclusion in your policy?

I'm not for sure, but I know my insurance required THREE co-morbids. Rediculous, I think, but that was their rule.

Hi- I too have recently been denied by UHC-EPO. I have a BMI of 42 and am diabetic and have high blood pressure & high cholesterol too.  I was told that "weight loss surgery"is excluded under my company's (AIG) plan. I sentmy denial letter on 9/11/06 and they received it on 9/18/06. They have 15 calandar days to answer my appeal. I am hopeful that they will give their consent but I will just wait and see and then determine where to turn next.  I am not going to take this denial sitting down and am planning to FIGHT THE FIGHT!  Keep your chin up and don't give up....Appeal all the way if needed!

I wish you luck!  My denial letter had a fax number on it as well as a mailing address so I faxed mine.  My plan DOES cover the surgery but my surgeon turned in the wrong weight and BMI the first time so I am having to appeal with my correct information.  I too have a 15 day wait to see what they say. I agree with you, Fight, Fight, Fight!  Sometimes though, it's almost too frustrating to think about it.  There are times when I just want to give up and try to finance it or something but I feel like if I qualify and my plan covers it, THEY SHOULD PAY! Good Luck and Keep in Touch Tara

I have a similar insurance, and they have been horrible.  I was told, from my employer (who has employees that sit on the appeal board by the way, can you say 'conflict of interest'?) that the denial was due to the proceedure being 'experimental'.  When I asked about how my co-morbid conditions might affect the outcome of the appeal, I was told that my medical information was irrelevant, and that I had to prove that the proceedure was not 'experimental'.  THE DENIAL OR APPEAL IS NOT INFLUENCED BY MY MEDICAL CONDITION.  What the heck do I have HEALTH insurance for then?