Question:
Employer exclusion--Help!

My pre-determination has been denied by United Healthcare due to a written exclusion in my employer's policy with United Healthcare. The exclusion states that "expenses are not subject to reimbursement for surgical treatment of severe obesity where the individual's body weight is less than 100 lbs. over the normal weight for his/her frame". I sent a letter of appeal to United Healthcare and my employer. My employer denied it and said they were not obligated to approve, even though I meet the guidelines according to the NIH. I called United Healthcare and they said that they cannot override the employer's decision. I have co-morbidites such as hypertension, sleep apnea and GERD. My BMI is 38. Do I have any chance at all to have this decision overturned?    — J. K. (posted on March 17, 2005)

March 17, 2005
I would get an attorney to appeal this exclusion. I would argue it is so poorly worded as to be irrational and meaningless -- 100 lbs. overweight is a general guideline and BMI is the usual medically relevant categorization: someone who is 100 lbs. overweight can have a BMI of 44 if s/he is 4'10 (110 lbs. at that height is a BMI of 23), and 34.7 if s/he is 6'6" (200 lbs. at that height is a BMI of 23.1). Moreover, the exclusion without considering the NIH guidelines is probably contrary to accepted medical practice, as a BMI of 35-40 with co-morbidities is considered to make WLS a medically necessary procedure. Get thee to a lawyer!
   — [Deactivated Member]

March 17, 2005
I would get an attorney to appeal this exclusion. I would argue it is so poorly worded as to be irrational and meaningless -- 100 lbs. overweight is a general guideline and BMI is the usual medically relevant categorization: someone who is 100 lbs. overweight can have a BMI of 44 if s/he is 4'10 (110 lbs. at that height is a BMI of 23), and 34.7 if s/he is 6'6" (200 lbs. at that height is a BMI of 23.1). Moreover, the exclusion without considering the NIH guidelines is probably contrary to accepted medical practice, as a BMI of 35-40 with co-morbidities is considered to make WLS a medically necessary procedure. Get thee to a lawyer!
   — [Deactivated Member]

March 18, 2005
As long as the word surgery is not in the exclusion you have a chance. Your co-morbidities make even more likely you can fight the exclusion. It sounds like your employer is being the stinker, not the insurance company. I would hire a lawyer. Good luck!
   — TheresaC

March 18, 2005
My employer has an exclusion for this surgery. You can read my profile and my journey. I used Obesitylaw.com, Walter and Kelley Lindstrom, they are awesome, and I won! Jennifer (RNY 12/17/04 Lap) Please contact me if you want to chat about my journey.
   — jenniferw