Immediate and Accurate Input

For those not familiar with who I am look at past posts.  Here is where I am now.  After reveiwing all the data the insurance Co.  United Health Care decided my excluded procedure has left them with no choice but to once again deny my procedure even though they sent me an approval.  They have now placed me in the hands of an appeal board that I may appear before in person even though its 7 hours away.  They are going to decide my fate in ten minutes.   That is the alloted time.  The screener has informed my I should send them any supporting documentation I have however they will not , according to her reconsider on the grounds of medical necessity.  I asked what I am supposed to provide and she informed me what ever I have that may add credence to the procedure.  I asked what? She again said anything I have.  So I have asked my Dr. , my shrink and my boss to write a letter as to the social, economic and health benefits of having surgery with out emphasizing medical necessity.  I have two days to get all of this to the board plus a 1 inch think packet of medical paperwork that they are going to discuss in ten minutes over the phone in a conference call.   I have contacted three attourney's not one will touch it.  I have written the commissioner of insurance which led me to the appeal however apparently no insurance law was broken.  The VA is not an option. I am almost certain this is such a farce but given the fact I have two days to get this taken care of  and get them the info my options are minimal.  Any experience with this? Any suggestions?

I really do not have any imput....other then to say good luck. Scott

United Healthcare sucks with this type of thing. When I started to research surgery I read the summary of benifits my wifes employer handed out it said surgical treatment of obesity was excluded unless medically necessary. I called the 800 number was told it was excluded. I explained that I had comorbities etc. they said that it would be covered. I spoke to a supervisor got names.... Went to the surgeon submitted for approval and was declined the summary of benifits could not have been clearer the policy excluded wls regardless of medical necesity.

I called back spoke to the same supervisor was told she was sorry for the bad info but there was nothing they could do.

I was lucky and was able to go onto my employers insurance for the year and had the surgery 9/24.

I have no input other than to wish you luck and share my experience.

 

Jon

Could you call your state representative's office.  Ask the rep's office to talk a state agency that could be responsable...May not help but is worth a try.  Also on this web site, (I think) there are standard letters that can be printed out talking about the benifits of the surgery.  Good luck, Brian

Called him there is little he can do except introduce legislation into a new law.  Talked with him, his aid, commissioner of insurace, 3 state agencies that work with insurance.  They want me to write letters for futrue reference but little  they can do now becuas UHC is a private company.

Davo, I still don't understand why the VA is still not an option.  They treat coverage very much like a regular insurance policy these days. I was told if I made too much money or had other insurance that they would charge me copays of $8 and if I had other insurance they would bill the insurance company. However, if there where procedures not convered under other insurance that it would be covered by the VA. So if I where you I would dig deeper into the Veterans insurance to see if the procedure may be covered since your other insurance has an exclusion. Also, check to see if there are any studies going on in the Bariatric department and if you qualify to get into the study. I would keep poking at the VA if I where in your shoes. Good Luck and I hope to hear better news down the road.

According to VA I make to much money.  I called and talked with a screener and they said no my qualifications for coverage do not satisfy them.  I also talked with counselor for VA and she said same thing.

Well,, a couple of ideas here, if they help ...     First of all, re:  lawyers, did you try contacting the obesity law lawyer in San Diego, Walter Lindstrom?  He has pretty good success at getting arpproval, so long as there is not a blanket exclusion for weight loss treatment in your policy (those are pretty insurmountable) ..  It sounds like you don't have the blanket exlcusion situation, though ..  There is another obesity lawyer (I think he's in NY?) .. can't remember his name, but he supposedly has a lot of success for his clients, too ..    Secondly, hasn't your surgeon's office helped to get you approved?   I think most of them these days have a full-time staff member (or even more than one) who has that as their primary (or only) job ..  It's an evil necessity of the profession, and knowing how ins. cos are increasingly bogging down the approval system .    Another thing to consider is getting a cash loan to pay for the surgery, using one of those services (I know of one gal that put hers on a credit card after getting her credit limit increased!) ..   You could then take your time making your ins. co. reimbuse you for the cost later, so you can pay off the loan, once you prove up "medical necessity" to them  ...   Lastly, I know of a gal (a former client and close friend, too - who weighed 500+ lbs.) who got her VBG approved from Blue Cross of Texas only after she "faxrassed" them ..  She simply faxed them copies of ALL of her medical records until they approved her ..   We're talking stacks and stacks of paperwork, several inches thick  ..  They couldn't shut off their fax b/c of other customers/insureds that needed to fax them things, so it was either have her tie up their fax machine or approve her - and they did!   (pretty sneaky, but I don't know if it would work today with caller ID stuff - but then I guess you could fax them from different phone #s to get around the block!)   &;-)      Best of luck to you and please let us know how it goes ..

My exclusion is any weight loss surgery or non-surgical procedures.  Basically they cover nothing ever.  I however was told to submit and appeal.  I even got an approval which was a mistake reported on by them.

Geez!  This is a tough one!  Sounds like they have their minds made up. Don't they understand that they save money in the long run by helping you to get thin and healthy? All I can say is Good Luck! I'm glad my insurance said yes right away. I feel for you!