United Healthcare (UHC) - One WLS Per Lifetime Limit - Seeking positive REVISION success...

appealing a covered procedure and appealing something not covered are two different things. And yes,actually,I used Lindstrom to try to overturn an exclusion my insurance has to any WLS.

i paid $800.00 and we went thru the whole thing,only to have Lindstrom not be successful in winning my case. Do I blame them? No. It is what it is so I speak with much experience. 

I sincerely wish you all the luck in the world. Maybe Lindstrom. Can help you. 

As you see,I am certainly not passive,but I am a realist. I know when to quit beating a dead horse. 

This is very limited response as there is a lot that goes into an appeal and I don't know your specific issues etc.   A Surgical complication is NOT treated as bariatric surgery, a fistula post RNY is uncommon, single digits%.  The argument with your case is fix the fistula, no need to RNY to DS (of course this is not what I think, but a one time surgery it will be almost impossible to reverse this)  I assume you have the connection from the new pouch to the old stomach?  you can fix that without RNY to DS...see where this is going?  that is something that will be brought up.  Now if you went in to fix your fistula I am certain it would be covered, so you cant argue RNY to DS conversion due to fistula, as your fistual can be "fixed"  and you don't need a RNY to DS because of your fistula-understand?  pretty much all insurance plans pay for surgical complications.  A surgical complication, fistula does not warrant RNY to DS, it does warrant fixing the fistula and continuing with your RNY (with your one time surgery lifetime) now if you have surgically attemped to fix your fistula and it failed and you still have ulcers, and pain, that may be a different story, but even then, it will be an uphill battle, and not sure you could defend your position to go from RNY to DS....I wish you all the best in your journey to health

I'm not sure what State you are in but I had UHC when I had my Gastric Bypass in 2012. I lost 120lbs but my Stoma is huge and I have 0 restriction. My pouch wasn't great either and I totally stopped losing weight at 7 months. I went to court with UHC and had TONS OF EVIDENCE even my surgeon saying my surgery failed! I STILL lost because of that rule here in Michigan 1 procedure per lifetime. Fast forward 2015 I have private Blue Cross Blue Shield PPO I have a $1,400 total out of pocket which I met with all my pre surgical testing And they are covering my Duodenal Switch @ 100%. Look into the DS.

I am in California and work for a company with greater than 50 employees. If it were less CA mandates coverage. I likely will not be able to keep working or afford to get other insurance due to my weight and joint pain. 

The best answer I can offer is what I ended up doing myself. My previous employer not only had a one surgery per lifetime policy, they also stopped covering the surgery in it's totality on 1/1/14.  I have since switched to a new employer who has a different insurance company (UHC) (not at all 100% of the reason that I changed jobs). The one per lifetime only pertains to the "lifetime" that you spend covered by their insurance. As far as UHC is concerned, I have never had a WLS procedure because they have never paid for one for me.  May be something to think about for you...

Well, the good news is that I got my revision approved on a technicality.  Although UHC paid for my first surgery 12 years ago, it was under a different employer plan. Now that I work for a new company, I have a new plan and policy. Therefore approved.  I also called them every single day and advocated for myself.  So, nothing is "iron clad" and I encourage everyone to be their own best advocate. My revision Surgery is scheduled for April 10th with Dr. K !  Happy, worried all at the same time. 

Hi Douglas - just checking in to see how you are doing post op.  My revision paperwork was submitted last week (I think) so I'm not in approval limbo...