UHC Denial Confusion

I'm in the throes of the approval process for United Healthcare.  I meet all of the eligibility criteria written into my policy (and I've had 5 different people read me my policy verbatim, so I know what it says!) My policy requires "1-2 separate documented weight loss attempts, such as Weigh****chers, Jenny Craig, etc."  That's a pretty nearly exact quote, and the only mention of weight loss efforts in my policy.  I sent them a 7 month physician supervised trial of phentermine from a few years back and 11 months worth of documentation from WW that is far more recent.  They denied me because I didn't have a 12 month physician supervised WL program.  What the???  my policy doesn't require that!!  It's not written anywhere.  I have sent documentation for everything that they require and meet all of the criteria. Is this just denying to deny and hoping I'll give up?

Call ins company and ask them about the 12 month supervised diet.  And don't give up, go to the dr and start a sup diet.

Who did you get the information from about not needing the supervised diet? The reason I ask is this, usually the first person you speak with (cust serv rep) does not have enough brains to access all of the information, they will tell you that you have coverage, your BMI must be 40 or 35 with co-morbid conditions....blah blah blah...to get the actual criteria,  I usually have to speak with about 3 different people and usually I have to ask for the pre-determinations, utilization management or pre-cert departments to find the actual people who do the review. The customer service reps, although nice and helpful, usually cannot access all of the info. I usually send out 5 or more UHC pre-determination requests per week and I would say over 80%of mine require the 6 month MSD (medically supervised diet). Also, where is your denial letter? All the ones I see in my job specifically list the reasoning for the denial...example... "the proposed procedure is not medically necessary....medical necessity is determined when....BMI of at least.....at least 18 years of age"....and on and on as a list of criteria...usually the supervised diet is mentioned in there..... Your denial letter is your bible, you have to make sure each item on the denial is accounted for. UHC usually only denies my patients when something is missing (like a poorly documented diet program) or not clearly identified (like a letter from a psych), I typically only see denials ofr no good reason from Cigna.  I would double and triple check what you sent. I have seen some policies accept Weigh****chers only if in conjunction with monthly doctor visits and very few that accept only WW and no MD visits. Also is the documentation you have any good? Are your doctors notes specifically addressing diet and exercise or do they say follow-up flu, etc. Many of my patients think they have a supervised diet in their records and when I see them, there is no mention of diet but the patient gets upset when they get denied. Anyway, your denial letter should tell you all you need to know, but deciphering it usually means you have to read it 4 times. They make it hard on puropse. Let me know if there is anythign I can do for you. Bonnie

Thanks, Bonnie... I have had the eligibility criteria in my exact policy read to me verbatim 5 times but five different people, customer service reps, managers, care coordinations, etc, and it's been completely unchanged every time it's been read to me.  The exact wording in my policy is that WW is considered acceptable if documented, and they have 11 months of documentation.  There's also no time creteria written into my policy, so technically my Phentermine trial would also count.  I have also talked to my HR department about it because my friend who has the exact same policy from the exact same employer didn't have to do ANY of this... she just had to supply 5 years of weights. Also, 2 surgeons offices that I have worked with have gotten the same information regarding the criteria.  My file got all the way to the medical director before being denied which would be rediculous if all the documentation wasn't there to satify the lower levels.  I don't know exactly what the surgeon's office sent over, but I know what I sent the surgeon's office, complete with itemized list. 

I have not received my paper denial letter yet, but also had it read to me verbatim.  The wording was something really close to "Not covered due to lack of documentation of 12 month physician supervised" blah blah blah.  I look forward to seeing it.    I'll post again when I get it if it's not clear.   The whole thing is just really strange to me, especially since I do have a friend on the same policy having surgery next week that just breezed through it...

I also have UHC.  I only had to have five years of weight history.  My BMI isn't 40 either.  I was very surprised to get approved in less than two weeks.  I was getting everything together in case I had to appeal it.   Who is your insurance through?  My UHC is through the railroad.  That may make a difference also. I hope it all works out for you!

Thanks... I'm working on it! My UHC is through Children's Medical Center of Dallas.  Your requirements sound the exact same as my friend's, and she didn't have to go through the whole approval process at all, which was wierd to me.   The strange thing?  She and I have the exact same policy through the exact same employer.... 

After getting HR and our company's UHC rep involved, my denial was overturned in 24 hours.   I told them my policy didn't say that :).