UHC insurance trouble

Hey everyone!

My name is Lisa, I'm 23, and I'm trying to get either the band or VSG. I'm covered under my dad's United Health Care plan and they cover the WLS if I can show proof that I've had a BMI of 40+ for the past five years. The problem is I've only had a BMI of over 40 for the past two years... before that it was 38 and 39. Has anyone else run into problem like this with UHC!?!  Any ideas on how to get around it? I'm considering self pay but if it's possible to fight for it I'll do it! Thanks for any help!

I'm in the /same place.  I've sent off for a copy of  the witten policy and I'm waiting to see what it actually says so I can write an appeal.  Do you have anything wrong with you such as high blood pressure

If you want to read their policy, go to www.uhconline.com; click on tools and resources, then select policies and protocols from the left side.  Once there pick medical policies, click 'agree' then go to bariatric surgery.  Once there you'll find the Coverage Rationale, but it is worth reading the whole thing.  Do you have: high blood pressure? diabetes or prediabetes?  back problems from being overweight?  Have you had a sleep apnea study yet? High cholesterol or triglycerides?  High blood pressure?  I wouldn't give up on the first denial though - it is always worth an appeal.  I'm working on one for a VSG.  Good luck. 

here's the text from their website under Coverage Rationale:
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Coverage Rationale
Gastric bypass (Roux-en-Y; gastrojejunal anastomosis), vertical banded gastroplasty (gastric banding; gastric stapling), adjustable gastric banding (laparoscopic adjustable silicone gastric banding), biliopancreatic bypass (Scopinaro procedure), biliopancreatic diversion with duodenal switch, and laparoscopic bariatric surgery are proven in adults for the treatment of clinically severe obesity as defined by the National Heart Lung and Blood Institute (NHLBI) who are:

1.     Morbidly obese (BMI of 40 or greater)
2.     Severely obese (BMI 35-39.9) with at least one of the following obesity related comorbidities

• 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
   
• Moderate to severe sleep apnea with a respiratory disturbance index (RDI) of 16 to 30 (moderate) or apnea-hypopnea index (AHI) >30 (severe) as documented through the completion of a laboratory based polysomnography.
  
  The gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic sleeve gastrectomy) when done alone and not a part of the full operation to complete a biliopancreatic diversion with duodenal switch is unproven due to inadequate clinical evidence of safety and/or efficacy in published, peer-reviewed medical literature.
  
  The mini-gastric bypass (MGB), also known as laparoscopic mini-gastric bypass (LMGBP) is unproven due to inadequate clinical evidence of safety and/or efficacy in published, peer-reviewed medical literature.
  
  Robotic assisted gastric bypass surgery is unproven due to inadequate clinical evidence of safety and/or efficacy in published, peer-reviewed medical literature.
  
  Bariatric surgical procedures in a person who has not attained an adult level of physical development and maturation are unproven due to inadequate clinical evidence of safety and/or efficacy in published, peer-reviewed medical literature.

Mine is going through UHC also.  I'm just now to the point of waiting to hear from them.  Everything has been submitted.  I am in the same boat with the BMI.  I actually had to go in and have them do a height check on me because they had it anywhere from 5'4" to 5'6"...which makes a big difference with BMI.  so, I made sure to slouch as much as possible for that height check!  LOL  It came back at 5'4".  However, they also found that I had several co-morbidities such as high cholesterol and a couple other big fancy terms for high triglicerides, etc.  Those go in conjuction with the higher BMI and I think it meets the criteria.  I'm still waiting to hear though . Good luck to you!

Lisa,

I too am in the same boat as you;  my BMI has only been over 40 for a year, but it was between 35-39 for the last two, so I do meet that requirement for UHC.  Have you had to go on a six month supervised diet?  I had to do that -- again, because my BMI wasn't over 40 for five years.  Unfortunately, after completing my six month diet, I discovered that I did not have a comorbidity -- or at least, there's nothing in my medical file that proves I have one.  I've always had high cholesterol, but apparently didn't have it checked in the last couple of years.  I had a lipid panel done this past March, but I need proof that I had high cholesterol in 2007 or 2008, not 2009.  It's crazy.  So UHC denied my initial claim, and my surgeon's office has submitted an appeal, using my hypothyroidism as a comorbidity; I'm very doubtful I'll get approved, because looking at the UHC website, hypothyroidism is not what they consider a comorbidity.

So, do you have high blood pressure, sleep apnea, high cholesterol, or diabetes?  Because if you do, you should be able to get approved.  Hopefully you've chosen a surgeon with a competent insurance staff who will know how to go about getting this information, in the proper form, to UHC.

Good luck to you!

Beth