Employer exclusion--Help!

My pre-determination has been denied by United Healthcare due to a written exclusion in my employer's policy with United Healthcare. The exclusion states that "expenses are not subject to reimbursement for surgical treatment of severe obesity where the individual's body weight is less than 100 lbs. over the normal weight for his/her frame". I sent a letter of appeal to United Healthcare and my employer. My employer denied it and said they were not obligated to approve, even though I meet the guidelines according to the NIH. I called United Healthcare and they said that they cannot override the employer's decision. I am 5'3" and I weigh 214 lbs. I have co-morbidites such as hypertension, sleep apnea and GERD. My BMI is 38. All preliminary testing has been done and claims have been paid. My surgery date has been postponed. Do I have any chance at all to have this decision overturned?

I typed you a reply but for some reason it never showed up on here. We have them and when we called UHC, we were told the BMI had to be 40. I believe if you put your height and 226 in there it comes out as 40. So you have to play the game and gain 12 pounds. Be sure not to lose it before you enter the hospital......... the sneaky Ins. co. may check records and insist that you are weighed and if you are under oooops no pay. So you need to have an additional Dr. visit where you are measured at say 230.... wear heavy shoes. They are liable to demand to have your weight verified. So you really need to qualify, by gaining a few pounds...... I would do 14, and not lose it before hand. They may get sneaky and make you do a supervised diet for a couple months, if they do, gain 2 more pounds.......... thumb your nose at them. It is really silly that they make people to go to such lengths, and you know that they know you only had to gain a few pounds, they are counting on you not doing it. If they come back about the weight, write them a personal letter that you were down after their denial!

From friends I have heard that if there is written exclusion in your policy, then whatever you do, they will continue to deny, now from reading, you said that if you are 100lbs overweight they may do it, find out exactly what is in the policy. If it is written exclusion w/ an exception you might have a chance. Why is your employer denying this and not the insurance co. That is weird, if you have ins through your job, that is what you are paying for, why are they saying the employer said no? I wonder if they mean that when your company decided to get the policy with that particular co they decided against bariatric surgery (written exclusion) because it may have cost the co more money. I am 5'3" 255lbs and my BMI is 45.2. You keep fighting and do not give up!!

While you are "waiting this out" make sure you have your PCP place you on a "supervised diet" with follow-up visits that include your height and wieght on each visit. Since 11/2004, most insurance companies require you be on a physician supervised diet for 6 months with monthly visits to the PCP--you can't just call in the weights, you must be physically seen by the doctor and he/she must document that they are supervising your diet. Next part, contact your local state vocational rehabilitation service. They usually have funding for medical procedures that would either prevent you from becoming unable to work or to assist you in returning to the work force. You have comorbilities which will also assist you in qualifying with your VRS. Even if you win the insurance battle with UHC, it might take a long time. VRS might be faster and it wouldn't hurt to start the process with them. Allison in AL