UHC EPO - What do you guys think?

I believe I posted previously that I called to see if my insurance covers and they said yes and sent me to a nurse case manager who told me I needed 6 month diet.  My surgeons office said that when they called the UHC, they said it did not specify that I need the six month diet so we submitted....well while Im waiting, my husband got the policy for me today and just emailed it.
Here is what it says about the coverage:

17. Obesity Surgery

Surgical treatment of morbid obesity received on an inpatient basis

in a Hospital. All of the following criteria must be met:

· Covered Person must have a minimum BMI of 40;

· Covered Person must have documentation of a diagnosis of

morbid obesity for a minimum of five (5) years from a Physician;

and

Covered Person must be over the age of 21.

What do you guys think? Does this mean that since the poicly says I dont need it then I wont have to do it?

I have United Health Care and was approved . I didn't have a complete history showing my BMI/weight but I did get approved. I have a high BMI and other commodities. Pre diabetic and I had a heart stint put in this past April. I think you need a BMI over 40 and the commodities add more for your case. I did not have to do a 6 month diet. I was worried about the VSG approval and by luck the changed their position on VSG 2 weeks before i submitted. Hope this helps.

Check out the Medical Policy on line

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?chan nelId=016228193392b010VgnVCM100000c520720a____

Bariatric Surgery (it is a PDF file):


Based on the Medical Policy

Patient selection criteria for bariatric surgery includes:

1. 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.
2. 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.
3. Psychological evaluation to rule out major mental health disorders which would contraindicate surgery and determine patient compliance with post-operative follow-up care and dietary guidelines.

Looks like they do require the 6 month based on this -

I do believe every policy is different which is why they refer you to your individual policy. I guess my question was can they implement a 6 month diet even if you policy states you dont need one.

Most group contracts do not have specific medical policy language within the contract.  They will use terms that refer back to the published medical policies.  The primary exception is for union negotitated contracts which can *sometimes* spell out in the written contract what CPT and ICD codes are covered and which ones are not. There are good and bad points to each scenario.   As an example most benefit booklets do not specify under what cir****tances they cover an MRI of the breast, but I can pretty much guarantee you they do not cover it  in place of a routine mammogram.

If they were to list all the criteria in your benefit booklet in specific unambigious terms it would probably be over one thousand pages long ;)

I've never seen a copy of a benefit booklet from UHC, but search anywhere for the term medical policy, or any reference to the term medical necessity.  UHC uses the term 'unproven' in their medical polcies so they might use that phrase as well.

I already have a wonderful bariatric surgeon who, in March of 2013, did a gastric sleeve on me.  I lost a lot of weight, but then I hit a wall and could not get away from somewhere between 360lbs-375lbs.  I have crippling osteoarthritis in both knees and have been told that I really need to lose weight and have a bmi of 35.  Currently, it is 55.  My surgeon now suggest that I have a gastric bypass, which , at first I was scared, but I am now committed to doing it. However, I had Amerigroup (medicaid hmo) the first time,  Now I have UHC star plus (also a medicaid hmo). They will pay the surgery, but my surgeon needs a surgical assistant which medicaid won't pay for.  What do I do?

Call the case manager assigned to you and ask her to repeat the requirements,the moment she is finished ask her to fax you a copy of what she is reading?