Denied- anyone know what the deal is?

hey y'all, I am pretty frustrated lately at the progress this whole thing is making. I guess expecting road-blocks is part of this process, but I had heard a lot of conflicting stuff especially from my doctors office and now I'm really skeptical about what the truth is, and how I figure it out. My doctor told me that United Health Care ususally covers WLS as long as it's "medically necessary". So did my father. However, when my mom called them, and then when the doctor's office called them, and now, when I was denied, they said that they do not cover WLS even in the case of morbid obesity. This appears very clear-cut in their policies, and what I'm wondering is how my doctor could be so misinformed and also wait until I was through with almost all of the pre-op tests to submit my stuff for initial review. They really didn't need any of my info to determine that I wasn't eligible if no one is eligible. So, right now I'm wondering if anyone has gone through this and knows some of the true things. Has anyone gotten UHC coverage? What's this whole business of "medically necessary" and how is it determined (like, I I know it's usually like BMI of 40 or over or 35 with co-morbidities) but right now I need textual evidence that I can cite in an appeal. also, if anyone knows what my likelihood of getting covered is? I'd rather not fight for this if it's pretty likely that I will be refused still.

Ok, I am still in the process of getting things submitted but.... I do have UHC- At the time of my first consult at Vanderbilt, i met with the head of insurance for WLS. She  gave me a sheet that she has that lists the requirements for UHC approval. The list i have includes:
*PCP letter *BMI 40 or over/or 35-40 with co-morbidities
*5 years documented weight from PCP
*All documented attempts of weight loss in the last 5 years
*2 nutritionists visits 
*psych eval 
*2 support group meetings .
I have my psych eval next week and will be submitting after that. Ill try to find out where she got that list and let you know asap. Hope you get it worked out!!! good lucK!!
*Courtney

Courtney, Thank you so much for that info. I'm really hoping that my issue is just something like that... they definitely don't have all that info, so maybe they just denied me rather than saying they needed more info. anyway, I'm working on getting to the bottom of it, and I am hopeful that the people you got that list from know where that came from, that would be wonderful! Ann

Ann, I know insurace is a crazy thing and UHC has many different policies!!!   I had UHC through my work and they had they had an exclusion policy regadling WLS.   So I switched to my husband's insurance STILL UHC, and they clearly cover it.   Their only criteria is you have to have been morbidly obese for 5 years, so when my surgeon submitted my paper work I had to get 5 years worth of recorded weights from my doctors office.   I was approved within 2 weeks with UHC.   Each state is different, but in Ohio, they let you know within 30 days if you are approved/denied.    I definitely think this surgery is worth getting to the bottom of your policy and figure out what is going on.   You are worth it! Good Luck~Leslie

UHC is a company will a million policies - the doctors office should know better that your plan either does or does not cover - however many doctors are motivated by money so even if your plan doesnt cover WLS they are getting paid by you and the insurance for all the visits you already had. With that said its not the doctors office responsbility to check your benefits its yours. The doctors office is really only responsible for obtaining authorization for procedures that require them... if they dont thats the time they are 'penalized'. I believe you had posted previously and I advised you of a few options to find out if this is really covered. Check UHCs website - there should be a username and login associated with the plan - they summary plan description *may* be available online where you can read in black and white yourself if the procedure is covered. If its not available the HR of whomever the insurance is thru should have the plan books that break down everything that is or is not covered. You can also call customer service and ask them to read the ENTIRE benefit - its 99% of the time listed under the "not covered section" HOWEVER you need the magic words "if medically necessary". Its usually listed in the entire benefit so thats where confusion can come in with customer service - they see it under 'not covered' but there *may* be an 'if an or but'.  If its covered 'if medically necessary' then UHC can provide you with the guidelines required.  Now you stated you were denied - so your surgeon submitted for approval and you received a denial? If so then BY LAW UHC will send you a DETAILED denial letter in the mail - it will outline specifics as to why you were denied and what your appeal options are. This letter should easily state if you were denied due to not having WLS coverage. If that is the case you can follow the appeals process and try and get it overturned... you may also want to look into a lawyer to help your cause because typically if something is not covered, its not covered. Your state should also have a department of insurance or insurance commission that you can contact for further assistance. Keep in mind each state has its own laws/rules concerning insurance so not everybodies case is the same if they live in a different area. Its hard to say how your particular case will pan out, depends on the specifics.

Leslie, thanks for the info and encouragement :) jennifer, Thanks also for all the info. You are right about the earlier post, I'm sorry if it seemed like I ignored what you said about getting a copy of my policy. the truth is, it's been really hard to get. I have insurance through my university, which does not give students a copy of the policy. Since there were so many things that seemed to be indicating this or that, and other stuff, I didn't know how to find it and no one else knew either. My parents finally got ahold of the head of the Health center who helps students with insurance issues. After requesting a policy copy sent to "our attorney" she called my father back and was very helpful and even called UHC for us, who told me that I HAD NOT been denied coverage, just that they lacked critical information. which is of course, not at all what that letter looked like. so, it may not be as impossible as it seems.