Revision from Band to VSG-UHC denial- need help with appeal

 BTW MidwesternGirl-I read through a lot of your blog the other night.  It is absolutely excellent and a much needed resource for anyone considering WLS.  I can only hope that as many people as possible read through it and really take it to heart. 

Sorry - I haven't posted in a few days-worked a couple of nights in a row and then busy weekend with lots of family events, and trying to get all of my appeal documentation together. 

I'm going through the same thing with our UHC right now.  UGG!!!

 Okay-so a little bit of an update.  I received my official denial letter from United Healthcare last Wednesday.  As soon as I had it in hand, I called the my husband's company's HR insurance rep that we have been in contact with.  She was so helpful in explaining a little bit about this whole process, helping out with appeal ideas, and calming me down a bit.

First of all the benefits booklet that I had been reading through is our official policy.  There is not specific exclusion in our policy for one surgery per lifetime.  She said that actually is from the medical standards of practice for obesity surgery.  For example, standards that recommend WLS for a BMI of 35 with co-morbidities or 40 without co-morbidities-- or the standard that list the acceptable co-morbidities as Type 2 diabetes, high blood pressure, etc.


Another thing is the peer to peer review.  Basically I set it up at the wrong point in the process-before I was ever denied in the first place.  I had read about peer to peer reviews on the boards and figured it was my best shot at getting approved first time around.  What I didn't realize is that they had already decided to deny the case the first run through, because if they don't then it becomes an "accepted" standard for approving future revisional surgery.  They would be setting a precedence.  Doing the peer to peer review at that particular time was kind of a waste.

The HR rep thinks that I have a very good chance of being approved on the appeal.  Since they have approved removal and approved replacement surgery, she said we just have to convince them that the lapband is just setting up future failure and the best chance for success would be with a sleeve. 

She suggested having my surgeon write a letter, as well as myself, and then to include medical literature supporting my case, medical files etc..

I requested a letter from my surgeon outlining info that I wanted him to mention, and he got an outstanding, very convincing letter back to me the same day.  Yay Dr. Robert Davis!!!

I have everything together and will fedex it all to United in the morning.

I strongly suggest that if you are having difficulties with your insurance and you work with a large company, that you contact your human resources department's insurance specialist.  She helped me understand the process, gave me tips, and even said that she and her manager where now aware of the issue and would be "keeping an eye" on the appeal as it goes through the process. Evidently the 2nd appeal would go to the company's own medical appeal unit (didn't even know that existed)

Anyway, keeping my fingers crossed and praying for a quick, positive response! 

Karla-how are things going with your appeal?

Its me, Karla...for some reason I cant find my "new" logon and its taking my "old" one...go figure

So, now they can't find the info where it specifically states only one per lifetime, so the ins co told the benefits lady that i didnt meet the criteria

so i called my dr's office and they were never given any criteria.

called ins co and they wont return my calls, so called benefits again. she faxed the only thing with criteria she had and it is criteria for ORIGINAL surgeries only, nothing spelled out for revisions at all

my bmi is 38.8, another 10 pound and i'm at 40 which is the no co-morbidiites level for original surgeries

getting cranky

meeting with dr on thurs   maybe we can get this hashed out then

Karla-

I honestly think that they will just try anything and everything to get people to give up trying to get the surgery approved- at least that's what it seems like!  

It is so frustrating-I just wanted to have my surgery over and done with and on the way to being healed by now so that I could feel better by the time summer got here.

I turned my appeal in last week and am now waiting to hear a decision.  The HR insurance rep suggested that I could get a letter from the first surgeon that I saw as a second opinion to add to the appeal, so I am working on that too.

Let me know what you find out.  I had the same problem with the insurance co not returning calls also-did you have to go through a secondary company that handles united's bariatric services also?  That is another thing that delayed this whole process another 2 weeks in the beginning-just trying to get the insurance case manager to return calls and turn in the case!!!  

I'm dealing with the folks at "optimum health", whatever that is, exactly.

I printed off the form for questions regarding decisions that I can fax in, but if I don't get to talk to a real person tomorrow, I'm gonna dust off the attorney attitude and see where that gets me. 

 I had to deal with optum Health also. Have you been assigned a case manager yet? Once I was assigned a case manager it took forever ( like 4-5 days) for her to ever call me back when I left her a message.  Which is ridiculous. It actually took like 3-4 weeks just to get denied the first time simply because my Dr.'s office and myself could not get in touch with my case manager (the actual denial part only took 2 days).

 One thing that I found I could do that actually got me through to my case manager was-instead dialing her extension, I would talk to an operator (I think you dialed 0 or waited on the line for someone). Then that person has the capability of seeing if she is on a line and can even send her an instant message to tell her that you are waiting on the phone.  It helped for me a couple of times, although a few times she was either in the middle of a call or meeting so I would still have to leave a message.

Now they are saying I need to meet the criteria for new surgery.

BMI is done
Psych eval can be done
6 month med supervised weight loss attempt...umm...I have a lapband, I think I can get that knocked out
Center of Excellence is done

Just annoying.  They know a new band isn't the answer, and they know that costs for me will go up if I can't get my weight back down because, lets face it, I'm not exactly a young duck here.  I'm 40 and things are going out of warranty all over the place.

I think I'll get what I need and what I want, its just going to take longer than I wanted.  I was hoping to have this done and over before summer so I'm not dealing with all three kids all day while I'm trying to recover.

 Karla, 

Just to give you an update--I talked to my HR insurance rep a little while ago and she informed me that the are overturning the denial decision and have approved the procedure.

I'm really happy and just have to say that I really think persistence is the key. They count on the fact that most people will lose the umpf it takes to jump through their hoops and they will then get away with not paying.

Have you gotten an official denial yet?  If not, this is my thinking--go ahead and let your dr's office put through the case for approval, you can be getting the appeal information ready and have it ready to send off as soon as you get your denial letter.  The way that my HR insurance rep explained it is that if they start approving people on the first attempt, then it becomes "standard procedure" and they are obligated to approve everyone on their first attempt. Which of course makes sense to you and me that they should approve them that way, but like MidWesternGirl said earlier in this thread insurance companies are NOT logical.  They are going to try to get away with not approving as many as they can.

Good luck and keep the faith-be persistent and hard-headed and you'll win out in the end!

I also have UHC and I am having a hard time getting my procedure approved. I have a lap band and I was self pay in Mexico (it was great). I recently had a baby ( after 100 pound wt loss) and my lap band Iis no longer in place, according to my surgeon. I have been having horrble N/V. They want a 6 months wt loss history,so i provided a letter from WW that gave a 15 month history. I was not able to provide the actually card because I had a flood in my house, which I provided intormation. I went to my PCP who has been following me for the past 4 yrs. He does my band fills and manage my HTN. He agreed to give me diet history but I would have to fill out a form to get my medical records from his old office. Well they never sent them so his office nurse called UHC (optum health) and told my Case manager that I only was seen by my doctor twice this year. I called that nurse and asked her why she called them to tell them that and she had no answer. My case manager called me right away to tell me what the nurse said as if I was trying to pull something over their heads. I am frustrated with this whole process but what kills me is I have all the requirements for my revision but they will approve to take out but not to revised. Where should i go from here? should I have them deny so I can appeal?