Question:
Can someone please help me? Do you see this as an exclusion?

   — Mary S. (posted on October 28, 2003)

October 28, 2003
Yes, and no. That is the ins company's way of insuring that the surgery is only for someone morbidly obese (usually 100lbs overweight or a BMI of 40 or greater). They probably have some rules and regulations, i.e., 6 months dr supervised diet and/or comorbidities. It just has to meet criteria AND be authorized.
   — tmchase62

October 28, 2003
The first part of that is the standard UHC exclusion. Given that there is that added part saying that it has to go thru the plan administrator tells me that your policy is most likely self funded thru the employer. I have never seen an exclusion like this in my life with UHC. I would assume that the WLS question has been brought up with the employer in the past and this was they're way of addressing the exclusion. It's definately not iron clad and worth a very good shot!
   — RebeccaP

October 28, 2003
Ok, now that I think more about this it really angers me. Several years ago UHC adopted a rule that changed the way 'approvals' were done within the company. They left the decision of medical necessity up to the doctors and not the insurance company. That is why UHC has been easy to get approvals from, because if it is not excluded from your plan and the doc says its medically necissary...then they have to approve it. What this exclusion is stating is that they are taking that decision away from the providers and leaving it up to the plan administrator...which unless its a rare plan, would be UHC.
   — RebeccaP

October 28, 2003
I think it is covered, but they like to deny it. IF they do deny you it sounds like you have an excellent shot at appeal with a lawyer. Let's hope it doesn't come to an appeal though! Good luck! :)
   — TheresaC