Question:
CAN ANYONE HELP ME UNDERSTAND MY POLICY WITH UHC PPO ?

MY POLICY STATES THAT THEY DO NOT COVER WEIGHT LOSS PROGRAMS WHETHER OR NOT THEY ARE UNDER MEDICAL SUPERVISION. WEIGHT LOSS PROGRAMS FOR MEDICAL REASONS ARE ALSO EXCLUDED. DO YOU THINK I HAVE A CHANCE AT SURGERY?    — PATRICE T. (posted on August 10, 2003)

August 10, 2003
Tough call. It all depends on what they consider a program. Personally I do not consider surgery a program. I think they may be referring to the weight watcheers, optifast etc. I'd go for it. Call them and ask about the process to get approval for WLS due to morbid obesity and other medical conditions and see what they say. If they say it is not covered ask them to point you to where in your policy it clearly says this. If they direct you to this statement then tell them this is not a program, it is surgery that permanently alters your body. Don;t give up without a fight. I think this one is vague enough that you might even be able to win it in appeal if it came to that.
   — zoedogcbr

August 10, 2003
I would definatly call them, I have UHC EPO and the covered 100%, but if it is through an employer it just depends on what they payed for......GOOD LUCK!!!
   — Saxbyd

August 10, 2003
I'm having the same problem right now. I was denied about 1 1/2 weeks ago and just sent my appeal letter. My denial was based on a general exclusion in my policy which states, "Health Services and associated expenses for the surgical treatment and non-surgical medical treatment of obesity are excluded." However, every time I speak with them on the phone they tell me that wls is covered for morbid obesity. I definitely meet that criteria with a BMI of 45.9 and many co-morbidities. Since the wording in your policy does not specifically exclude wls for morbid obesity, I think you may have a chance. Go for it, and don't give up!
   — angie305

August 10, 2003
stop sorrying. a "program" is like you going to Weight Watchers or a gym and asking them to pay. If your Dr. advises this, it will be for medical necessity. I have the PPO and my friend has EPO. Neither one of us were asked for anything extra or to jump through any hoops. Unless your employer has placed "weight loss surgery" as one of THEIR exclusions, you are fine (if you meet the BMI criteria). We work for American Express. Call the number on the card and ask this exact question: "Do you have weight loss surgery listed as an exclusion? good luck
   — Donya P.

August 10, 2003
Unfortunately I had the same exclusion as Andrea below and was denied twice for this surgery (BMI of 55). They said they absolutely would not cover this surgery and even contacted Walter Lindstrom and he let me know that he had never won a case against UHC. Sorry for the bad news but that was my experience. Seems like some people though can get through and around that?!?! Good Luck to you!
   — SMG I.

August 11, 2003
That is not thier standard exclusion for WLS. I would try it. UHC is very specific with the WLS exclusion.
   — RebeccaP