Gary, please help!

I began my Lap Band journey a couple of months ago.  I have United Healthcare through the railroad.  I called twice, before starting this jorney, to verify UHC's requirements.  Each time I was told it is 100% covered with a BMI or 40 or BMI of 35 and 2 comorbidities. I jumped through all the hoops set before me, only to get a message today from my doctor's office that UHC has my paperwork.  They said Charles at UHC said it's common now to require a 5 year BMI history and if my BMI is below 35 at anytime, I won't be covered. I called UHC and got a Care Coordinator.  He said he didn't know why no one ever told me about the 5 yr. BMI history because it's there in black/white.  I told him I could give him names and dates of who I spoke with each time I called UHC.  I told him I couldn't verify a 35 BMI for the past 5 years.  HOwever, I could verify a 5+ year physician monitored weight loss program. I have just about starved myself and smoked like a freight train, and took metabolife over a period of several years, to keep from being obese.  I have been at my current BMI for about 6-8 months.  My comorbidities have developed over the last couple of years.  I have dieted and been on diet medication all my life, to keep from being morbidly obese. I don't know what else to do.  This seems so unfair.  I have done everything I knew to do, from the beginning, (according to reps I spoke with at UHC).  I would never have spent this money or time, if I knew I couldn't verify evrything required.  Trust me.  I do not have a lot of money to just blow. Please help.  I'm so desperate and upset. Thanks, Melissa

My story is somewhat like yours except they told my doctor I would be covered if medically necessary with 5 year bmi history, which i have plus sleep apnea, diabetes etc.  then I spent all the money for the tests that needed to be done only to be denied saying there was an exclusion in my policy.  We tried appealing but that didnt work either. they said they didn't have the taped conversation where benefits were verified but they did have the ones where they said there was an exclusion. How convient. 

Yes, that is very convenient, for them!!!!!!.....    How is it that there is one set of rules for the insurance companies and one set of rules for the rest of the world??????  Have you been given any light at the end of the tunnel by anyone yet????  Has anyone offered you any advice/assistance?   I know I'm not a professinal and can't do anything.  However, if I can be of any assistance, or if you need a shoulder to lean on, I'm here.  I know that doesn't help get you approved.  But, I'm a good listener and can vent with the best of them.  It really suc@s the way insurance can manipulate the laws/rules to their advantage. Please keep me updated!! Melissa

Hi Melissa, I have some ideas for you to try...I work a lot with insurance preauths.  IF you have not sent into UHC there may be some things to try.  First of all Customer service reps don't have anything to do with who does the review of your preauth.  They often don't even have access to the criteria for your plan.  Even if you had the call recorded they are not responsible for giving you false information.  It is almost impossible to hold them to a benefit based on a call.  Recently I have been contacted by UHC medical review on one of the preauths I have submitted,  for the 5 year history.  Understand that I do not get contacted to submit this history on all of our UHC preauths.    One case did not have the weights in her records.  She literally was not weighed for 4 of those 5 years.  We were able to go back to years earlier and locate a weight that was inline for morbid obesity.  This requires combing thru records to locate the target weight.  Anyway UHC called me for the missing weights.  When I explained that they did not exist they went on with the review.   To my surprise she was approved.  It is always worth trying.  Just make sure the records submitted only have weights that are inline with morbid obesity.  It seems it is better to submit with none than with weights too low.  Another thought is to ask the treating doctor to document in a letter that states your struggle with morbid obesity and the high end of weight range.  Do not submit any recorded weights under range.  No BMI's under 35.   I suspect insurance companies hold onto these records and could hurt your chances in the future.   One last thought...Lap band company has an insurance line.  I would give them a call and see if they can assist you with your problem.  It really maybe in the presentation of your preauth to the insurance and of course it always is dependant on the reviewer who looks at your case.  Don't quit based on  a call with a customer service rep.  And appeal, appeal, appeal.    Another last thought....if your plan is thru the railroad...I would naturally assume self funded.  In that case some head of dept  in the HR dept for the railroad is the last say.  UHC would only be the administrator for your plan.  If they do deny I would immediately appeal to the HR dept of the railroad.   What I do every day for our patients is to keep looking for another angle and another way to appeal or go over some dept's head to another level.  It often works.    Keep thinking creatively and don't take no for the end all answer.  Ask any review dept person you can reach...what would it take to make that requirement?  What could I submit that would document that requirment?  Try to pick their brain a little while joking with them and you will often get some great information.  Remember you can't hold them to that information.....but it is useful information in understanding what they  are looking for and then plan on how to meet and document that requirment or to argue the necessity of it.   Good Luck, Mary

Mary, You are the bomb!  You have given me the most useful information anyone has ever given me on any of these boards.  Thank you soooo much!!  Granted, it doesn't mean I'll get approved.  However, everything you told me really helped. Do you think medical records for the last five years from my Chiropractor, showing my height, weight, and blood pressure will satisfy the insurance company's criteria, if they ask?  My insurance covers chiropractor sessions.  I only have a co-pay at each visit.  In addition, the letters written, recommending me for surgery by my PCP and my Chiropractor, both state they have been treating me since 1998 and what my weight is and how long my PCP has treated me for weight issues. I have osteoarthritis, degenerative disc disease, bulging discs,herniated disc, depression/anxiety, GERD, hiatal hernia, sleep apnea, stress incontinence, migraines.  My main concern though is my lower BMI being 35-36. What do you think?  Thanks for all of your words of wisdom.  They have had my paperwork now for 10 business days this coming Friday.  I was told not to contact them until they had it for 15-20.  It's so hard to wait, yet so scary!  I really want and need this surgery so bad! Thanks again, Mary!  Hope to hear from you again! Melissa

Awww Shucks....I just like whoopin' on the insurance companies. Your chiro records would do nicely...just make sure all weights are over a BMI of 35.  Go thru them and only submit those.  Anyone who has a BMI under 40 must prepare for a fight.   You must document all of your co morb's very well.  It looks like the bone, osteoarthritis issues. bulging and herniated discs and the sleep apnea would be the ones to concentrate on.  Make sure your treating MD or chiropractor send lots of documentation on the many health issues and treatments tried.  Include a sleep study and cpap titration.   I would expect a denial right off the bat so start to prepare your appeal thinking now.  You maybe pleasantly surprised but usually under 40 BMI gets denied the first round.  Some people I have "heard" of just weigh in at a heavier time and resubmit.  Usually goes right thru.  Don't give up.....It's always worth the fight.  I would love to hear how your case goes...Good Luck!! Mary

Thanks, Mary! I'm sure it varies by insurance companies, but is there a waiting period before being allowed to appeal to insurance company?  I have United Healthcare through Norfolk Southern Railroad.  Needless to say, I've never done this before...lol! What should I focus on in my appeal letter?  I don't mean to sound dumb, but I genuinely don't know what I'm doing.   Oh, trust me!  You will get a blow by blow of how everything goes!!!...lol Thanks bunches, Mary!!!!! Melissa

Hi Melissa, If you would get a denial letter they have to tell you exactly the process to appeal with them.  The good news in this is they also have to disclose exactly why you are denied.  Why is that good?  Well they must tip their hand and now you know exactly what you have to meet.  So make sure that whatever the reason is...you can document or do it and then send it in with your appeal.  If the letter is confusing to you call the numbers on the letter and ask them to clarify the denial.  Ask for exact details that the medical reviewer used to deny.  They legally have to disclose that to you.  Always pay attention to the deadlines in the appeal.  Obesity Action Coalition has a great website for appeal letters etc.  You will learn a lot on there.  The main thing is to not get discouraged.  While insurance companies can deny a preauthorization request they cannot deny you access to the benefit.  This means that thru the denial/appeal process you may lose a round or two BUT you can do whatever they are denying you for and then start all over with a new preauthorization request.  You can try again to access your benefit with new or changed cir****tances.  Some of our patients were denied on BMI issues and lost the appeals.  Later came in with a higher BMI and we just resubmitted the request....Approved quickly.  Sick to have to gain weight to lose it ...isn't it? I am looking forward to hearing the blow by blow of everything. Good Luck!! Mary