Which insurance to use???

I think I have ready every post on this board,,lol,,I too have the dreaded "exclusion" in my United Health Care Policy,,,however,,I have another option. I need some advice here. My United plan is my hubbys work sponsered plan, the exclusion says "Surgical treatment and non surgical treatment of obesity (including morbid obesity). THAT's IT,,,thats all it says,,,12 little words. So I called and the CSR and he said if I submitted a "medical nessessity" from my doctor they would review it and probably cover it.Now being that I have a BMI of like 55 and some comorbidities....I was wondering if that would have any effect on their decision, and their stipulations??? BUT,,,if United really wants to play hardball, I have an Ace in my pocket. I have been recieving disability for many years, and I am entitled to Medicare part B (already get part A),,, and I know Medicare will cover it. So what I want to get input on, is how long do I play with United before I switch my primary to Medicare and get this show on the road?? Also, if you were in my shoes, would you just submit once to United,,,or appeal before you switched to Medicare as the primary?? Hope I wasn't too wordy,,,I tend to do that... Vee

I would be leary of the CSR's statement that by just submitting a letter of medical necessity they would cover it. Your exclusion sounds pretty ironclad to me. This CSR may deal with other plans that do cover WLS and may not be as educated as he should be. But back to your question....I wouldn't fight long since you have the option to have this paid for by Medicare. I would submit your letter of medical necessity to United and then if you get denied because of an exclusion, switch to Medicare. Unless you are willing to fight long, hard and with money (i.e. hire an attorney) it is difficult to get passed an exclusion. Good luck! Laura

Thanks for your reply...I DON"T want to fight long, I don't want to waste ANY time at all. What you said was exactly the thought I had, but I wanted to get input from a neutral party, to make sure I was thinking clearly. Isn't it funny how a dozen words can make such a difference in your life. I guess I am lucky that I have the Medicare option. From the reading I have done here and on the internet, Medicare does cover the procedure, I beleive that a BMI over 40, (which I have), it is even easier because your don't need 2 co morbidities,,,,at least that is how I have understood it... ALSO, with all the UHC exclusions out there,,,do you think I should even waste my time with it,,,if it were you, would you just "cut the middleman" and go straight to the Medicare option?? Cause I was thinking of doing that too,,,my Medicare wont take effect till the following month that I start it. Thanks for you words Vee

Well I found out thru HR that United absoltely WILL NOT under any kind of cir****tances pay for WLS. So I saved my self the fight. I did find out that I can't just add Medicare, I have to sign completly OFF my hubbys United plan ( which will lower his weekly premium) and provide proof of medicare coverage to HR, and thats it,,,,then I sign up with Medicare and go from there. I am going to pay the extra for the Mediare Advantage thru Humana,,,,and I have already checked the coverage summary,,,and they DO cover the WLS 100%. Apparently thru the Medicare sponsered insurance programs they HAVE to cover whatever Medicare would cover. As Medicare has recently recognized obesity as a disease,,they now cover the surgery. Thanks for letting me vent!!!

Let Medicare cover it. If you fight the insurance company then your looking at weeks and even months of a battle on your hands. Believe me I know and I had to hire Gary to help me get approved. Donna 338/196 -142