Question:
Has anyone who has United Health Care -Select EPO ever won their appeal?

I am currently appealing United Heath Care - Select EPO for abdominoplasty 15831 and brachioplasty 15836. I was denied 02/21/03.The letter says the following: AT&T Broadband benefit plan excludes:Cosmetic procedures or services that change or improve appearance w/out significantly improving physiological function.<br><p> As we all know the procedures I am in need of are reconstructive after massive weight loss. I have letters from my PCP, WLS surgeon, Reconstructive surgeon, Chiropractor, Dermatologist stating the overhanging pannus of the lower abdomen, rashes, infections, back pain, neck pain, shoulder pain, hygiene issues, and problems with living a normal life because of all the skin. <br><p> I have requested that an ASPS(American Society of Plastic Surgeons) surgeon review my case. It only makes sense that a plastic surgeon instead of a general surgeon review my appeal, as they had a general surgeon review my original pre determination and you saw what happened. How can you have someone who is not an expert on the matter review my case?<br><p> If anyone has had to fight United Health Care - Select EPO or any type of insurance at United Health Care with similar denial wording please email me:<br><p> [email protected]<br><p> Thank you for your assistance.<br><p>    — Skyedancer4u1 (posted on March 1, 2003)

March 1, 2003
I can't answer this question but what struck was your comment on how someone who isn't a specialist can decide this surgery isn't needed. <p>My friend has a very serious connective tissue disease and she now needs treatments that cost $23,000 per time and right now she is getting them monthly. At the time they submitted to be sure they were covered either a nurse, family practice or internist reviewed and came back and said she should just use prednisone. Now factor in that in past years that is exactly what thye have used and many other drugs and she has gone through the gambit and this is the next locial step. Now add in that she is severely diabetic and prednisone is the WORST thing you can take if you are diabetic. They told her the person that reviewed this was a rheumatologist, which is who it should have been. I am about as sure as I can be it wasn't a rheumatologist because if it was then that person should have their license yanked. Fortunately she got hold of a very sympathetic supevisor and explained everything and that she was diabetic etc. and the lady said 'I think I need to get someone else to review this'. She did and my friend had her approval later that day. Here she has to live with this awful dibilitating disease and they give the review to some moron that has no clue about the disease. It's so rare that not many rheumatologists have dealt with it. It's just frustrating when you hear things like this. I hope you are successful in your appeal. Chris
   — zoedogcbr