Question:
My insurance denied, but there is exclusion... What should I do next?

My insurance is United Healthcare Choice Plus, I have in and out of network benefits. I have studied the policy carefully and it clearly states that tx or surgery for Morbid obesity is not a covered benefit, but there is an exclusion if deemed medically necessary. My denial letter I recvd. from UHC, stated that "even if it may be medically necessary, my policy does not include benefits for this proceedure."(why would the policy say it will cover care if deemed medically necessary in or out of network if they are saying there are no benefits?). My PCP has signed a letter that I wrote with all my diagnosis and medication I am on and diet pills and diets that I have tried etc. He signed it and said he agreed with everything that I had written and agreed that this surgery would be beneficial for me. The question I have, is what now? what else can I do??? What do I do if they deny it a second time? I know that United Healthcare is one of the better insurances that New Start works with, so I feel like there is still hope...plus I have been praying if it is His Will, then it shall be done. I just want to be sure there is nothing else I can do to help things along. Thanks.    — Marie B. (posted on July 17, 2001)

July 17, 2001
Marie-- Call United Healthcare Choice Plus and ask what the procedure to appeal the denial is--it may be listed at the bottom of the denial letter. If your coverage is through your employer, call your benefits department and ask if they have any suggestions. If you've read through this site, you know there are plenty out there who have been through what you have. Good luck!!
   — Jenny R.

July 17, 2001
I'm in the same boat right now. Every insurance policy should have an appeal process. Your initial inquiry was denied, so you can appeal. Check the policy (or better, call the person) and ask, politely, what you need to do to start the appeal process. My insurance company has been helpful in working with me to file the appeal, although they do tend to drag their feet at times. Good luck,,,don't give up.
   — Rosie P.

July 17, 2001
Hi Marie, I have read your profile also but there's no indication as to the type of surgery you're seeking approval for. I looked for this because of something you said in your question: that the ins co said that even if deemed medically necessary, the policy doesn't cover benefits for this procedure. That sounds as though it's that particular procedure which isn't covered, but if you should chose another, it may be covered. Some ins cos will not cover certain procedures even though WLS is covered. For example they may cover RNY but not DS or lap band. This is just something to think about.
   — dandjon

July 17, 2001
Does anyone out there have Midlands Choice insurance and if so did they cover your open RNY surgery. I have it and have been denied on all 3 appeals and evern had 5 drs letters sent in on the last appeal.
   — Trudy M.

July 18, 2001
I hate to br the "bearer of bad news" however, I was denied 3X the same type of thing w/ my insurance co. I appealed 2X and was in contact w/Walter who told me I would probably not win, because they are "self-funded Govt" type of inssurance co. I HOPE this is not your case and does not apply to you!! I have since changedjobs and my new insurance covers. Good Luck to you!!! '
   — [Anonymous]

July 18, 2001
I don't know why people respond as annonymous, what are you ashamed of? What do you have to hide? I tell ya...I am standing in faith with God the Father and believing that He Will make a way for me to have this surgery if it is His will for me! If you are the "Bearer of Bad News" why are you so ashamed to reveal yourself and let others look at your profile...It seems like people that don't want there identity known tend to always have nothing good to say to anyone.
   — Marie B.