What to do??? UHC.....

(On VSG and Main forum, too)

I received a letter dated 10/8 from United Healthcare approving the LapBand procedure but I switched doctors and submitted on 10/9 for the VSG. I called today to get the status of the VSG approval process and was told that a nurse made notes stating that I did not meet the 6 months of supervised diet by a doctor. Since then the case has been given to a medical director to make the final determination. Why would UHC have issues with the 6 months diet (which I was told numerous times was not required under my particular health plan,UHC Choice Plus) for one procedure but not the other? Has anyone else encountered something similar? Is there anything I can do at this point in the process? I'm nervous about the decision the medical director will make regarding my pre-determination process based on the nurse's notes.

UHC changed their bariatric medical policy on 9/17 and rolled it out 10/1.  The old policy excluded VSG but did not require 6 months supervised diet.  The new policy allows VSG but added this "additional patient selection criteria" that includes 6 month diet, psych eval and enrollment in a 'integrated' program.  that is probably why your band, submitted and approved under the old policy and VSG, submitted and approved under the new policy.

I have heard from some folks that UHC cannot just add a 6 month diet requirement to their criteria, that that is something that is negotiated and agreed upon in their company contracts.  You might consider talking up your HR chain on this one and see what they say.

Here is the text from the new medical policy:

Additional Information

Patient selection criteria for bariatric surgery includes:

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Documentation of a structured diet program whi*****ludes physician or other health care provider notes and/or diet or weight loss logs from a structured weight loss program for a minimum of 6 months.

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Active participation in an integrated clinical program that involves guidance on diet, physical activity and behavioral and social support prior to and after the surgery.

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Psychological evaluation to rule out major mental health disorders which would contraindicate surgery and determine patient compliance with postoperative follow-up care and dietary guidelines.