United Healthcare PPO - What the Heck!?!?

I’m applying for a lap band over a gastric bypass as a means for a revision since my insurance company (United Healthcare) doesn’t cover it.
Can anyone tell me their experiences with United Healthcare in terms of a lap band over a gastric bypass?   
The Specifics.... United Healthcare has told my Dr that they will be treating this as a brand new procedure (like I never had a RYN).  I never got to my goal weight (certainly not for lack of trying) and I don’t have any medical problems with my RYN. I just remained heavy (5'4 / 180 lbs)…and I’m getting heavier (272 lbs now).  
  My Dr. has since informed my that I’ll need to provide a 5 year history of being extremely obese 40+ bmi or 35+ with two comorbidities, I have one – high blood pressure (which I've only been treated for 3yrs). But I also had lower back surgery in 2007 and although I’m not taking any medication, my back pain is still there – probably a direct result of being heavy. I also have Restless Leg Syndrome which I have been treated for two years – again a direct result of being heavy.   I can’t seem to get any straight answers as to what qualifies and what doesn’t from my insurance company or my Dr. Anyone with similar experiences, advise, or direction?  All replies would be most appreicated.  Thanks everyone!

I have no advice to offer you as I have no experience with your particular situation, but I did want to wish you well on your journey.

No matter what they tell you NEVER give up and be your own advocate.

I am sure someone will respond to your post with the answers you are needing shortly.

I will keep you in my prayers.

I had UHC PPO, and my employer was self-funded.  They didn't have an exclusion but they did stick to their guns on the 5-continuous-years of 40+ BMI rule and denied, denied, denied me.  My BMI had approached normal before my lap band slipped and that was maybe 2 years before I started pursuing revision.  I hired obesitylaw.com and still did not get them to budge.  I'm lucky in that my employer has another option, they offer a local HMO in every one of their markets along with the UHC national plan.  I switched to that local HMO at the beginning of this year and was automatically approved, had my revision in February and am down almost 100lbs. 

I will never pay another premium to UHC as long as I can help it.

So I'm pretty sure that UHC PPO is my only choice.  I'm curious, did you have any comorbitities.  I've heard that they could slip on the 40+ BMI, if accompanied by two comorbities?  Did you have anything documented?  Any details would be so helpful as it appear I'll be fighting a long fight.

Thanks!

Goldie, Good Luck! I had to do the 5 yr hx when I had my lapband with Aetna PPO. Go to your Dr. and get copies of everytime you went to the Dr. and was weighed.  You could have gone in for a checkup or cold whenver they weighed you counts. If you can show you were over weight and maybe have sleep apnea, have a study it never hurts. Also any swelling in your legs could be lymphedema also causing your back pain.  Once I was diagnoised  and started tx for the lymphedema they pushed through the approval and I've lost 8lb.s in 10days and pains in my back and knees is much less.. Looking forward to RNY in 4 weeks. Miss Jean

It all depends upon your employer and their contract.  To be fair to UHC, they're just administering what your employer has determined they will cover.  I'm an AT&T retiree and can not get my ERNY approved as my BMI dipped below 40 for a short time 2 years ago (they have a 5 year history requirement as well).  I'm extremely frustrated.

My best advice, go directly to your employer and get a copy of the Summary Plan Desription.

Good luck!

Michele

Michele T - I feel your pain.  I work for AT&T.  Once upon a time they had insurance that was better than most by far.  Now it seems I'm paying more but getting less. 

I've checked out the summary details...and they do say in black and white that there has to be a 5 year proof of a BMI 40 and above.  I just can't get any straight answers about exceptions...is that 40 plus a comorbitity or two, and can it be below 40 but with certain comorbitities, and what is the thought behind having a surgery that wasn't completely sucessful before?  Too many gray areas and trying to get the details is what's most frustrating. 

How long have you been going round and round...and do you have anything helpful they have offered up?

Thanks for the reply!

I heard a rumor that United has agreed to cover the sleeve now...just for your thoughts.

Also, please let me know what you think of your surgeon.  I haven't heard much about him...just curious.

I am seeking revision to sleeve, so hoping that this rumor is true...looking to find out.

Oh wow.  That's great to know.  We just got the information at our annual enrollment is starting this month, I'm curious to see what they have added - or removed - in 2010.

I have to say that Dr. Ferrari did my first surgery 9 years ago...he was wonderful...then, when he was still a little guy with a small practice.  Now he's actually one of the leading Dr.s in Houston for obesity surgery.   I went him in July since I figured he'd be most familiar with his work, but I have to say this time around I've not been as happy with him, so much so I've been considering going to another Dr.  They seem to have so much business now, they don't really have time for the personal attention and time they did before.  He know's his business, but I think he's missing the personal touch he once had.

Thanks for your candid reply.  I am not as happy as I once was, either.  Sniffing around...we'll see!  Let me know if you fall in love with someone!  Good luck.  What was your first, and what are you considering now?