[Exhorter]

Well I got the letter today from UHC telling me why they said no.
This is what most of it said

Upon reviewing the submitted information, I have determined that at this time Morbid Obesity surgery is/are not a covered benefit under the benefit plan. This determination is based upon the following plan language, found on page(s) 20 of the member's certificate of coverage ( for fully insured employer groups) or summary plan descrition ( for self-funded non- ERISA employer group)

"Morbid Obesity: Benefits will be allowed for obesity when a surgical procedure is required due to morbid obesity. Morbid obesity is defined as a condition in which persistent and uncontrollable weight gain causes a threat to life because the covered person is either: Twice or more the ideal weight; or one hundred pounds or more above the ideal weight, whichever is greater. Accepted standard weight tables for frame, age, height and sex determine ideal weight. Surgical benefits will not be authorized unless; the condition of morid obestity has existed for at least five years, and Non-surgical methods of accomplishing weight reduction have been tried under physician supervision for at least three years, and a condition such as hight blood pressure, pulmonary insufficiency (lung disease) arteriosclerosis diabetes, coronary artery disease and the like indicates a need for surgery."

The benefit document covers surgical treatment of morbid obesity when the patient has documented morbid obesity for at least 5 years, has documentations of having failed at least 3 years of physician supervised non-surgical weight reduction treatment, and has a co-mobidity (e.g.. Heart, lung blood vessel or endocrine disease) that indicates a need for surgery (see the benefit document). The clinical information submitted and obtained for this review does not show that this patient meets any of these criteria except the five year history of morbid obesity.

Therefore the planned open revision of the previous vertical banded gastroplasty to a biliopancreatic diversion with the duodenal switch is not a covered benefit for this individual at this time under the plan.

Please note that this determinations is not a treatment decision; it addresses only payment for the services in question. Treatment decisisons are made between the member and the treating physician.

If the treating physician would like to discuss this case with the physician reviewer, he or she may call CAre cordinationa at 877 843-3210. The member will be provided upon request and free of charge reasonable access to and copies of all docmuments, records and other information relevant to the request. In addition the member is entitled to an explanations of the scientific basis or clinical judgment used in makeing our determinations. This includes o copy of any internal rules, guideliness or protocols used in making the non-coverage decision.

Members options
The following options are available to the member in responding to our coverage determinations:

1 The member has the right to authorize or designate someone to represent him or her in this matter
2 The member or his or her authorized representative may accept our decision as it stands.
3 The member or his or her authorized representative may request an appel within 180 calendar days of receiving this letter. Members who choose this option should submit all abailable additional information explaining why the requested service should be a covered benefit, taking into account the identified plan language.

Appeals request and additional informations should be sent in writing either by mail or fax to


Upon receiving the appeal request and any additional information we will complete our review within 15 calandar days for a standard appeal.

Then there is a section for Urgent appeals for those who life is very cridical from the time they made the decision but I did not put that in this letter.


So that is it in a net shell. I am 200 lbs over weight, I can hardly walk or stand anymore, my feet swell, my back hurts all the time, but because I do not have 3 years supervised diet from a dr. or any major killers at THIS time they are saying no.

So I wonder what my chances are I do not see how I can get that "3" years dr supervised diet thing. So not sure guys what will be next but I will not give up.

Sorry this is so long but whated to let you see what they said

[MsVickie]

Like i told ya honey have the Dr call. I would use the 200 pound thing against them. Mine specifically states if im 200 or more pounds ovewieght that is all they needed. I was offically 6 pounds short of that. Your policy has a statement about it to. Do you happen to have the Letter your Family Dr sent to the surgeon? It might not be a bad idea for him to write another letter with more content to it. I would send you denial letter to the Family Dr and see what he could come up with to help you out. You might be amazed. Have them send the new one to the surgeon so he can go off it to. You keep holding on.

[muffins]

I never dreamed that the day would come, when I have to eat to gain weiight. I got denied by UHC because I am not 100 lbs overweight. They even said my ideal weight is 123. So,I have to gain 5 lbs. That won't be hard for me. LOL

[Kenyar]

EX- look at it this way. Now that you have the letter and they are telling you exactly what they need, GET IT TO THEM ASAP. They want to talkto your dr. It might be that simple. Maybe they filled something out incorrectly or what have you. If its as simple as them making a phone call, STAY ON THEM TO DO IT!!!! This doesnt seem like a copletely closed door to me. I'm praying for strength and patience for you. This will work out for you.

[DianeB]

Don't give up hope--as Kenyar said stay on your doctor--he can make this happen for you--did he write down all the times you went to Weight Watchers, Tops, etc.? All of these things matter-see if he can call the insurance co. They want to make sure all the T's and I's are crossed and dotted . It will happen, wait and see. I'm pulling for you!!

[Exhorter]

My primary doctor is soooooooooo for me having this surgery. I have only been going to her for less than a year but she had had to treat me in her office twice for my back going out due to the weight pulling on it, plus three times for urinary tract infection, due to not being able to clean myself properly. So I will try to get her to fax another letter that will give more detail about those things to my surgeon before he calls the dr at United Health Care. I will not give up that is for sure

[Exhorter]

Well I finally got to take to the office manager today at the surgeons office and of course she had not received my denial letter. This is what happened
call the surgeons office second day in a roll. When this particular lady called back she is usually very nice but this moring she was what do you need? I ask if she had gotten my denial letter and she said NO it has not come across my desk yet when did you get yours? I told her 4 days ago and she said ok well fax it to me and I will look over it tomorrow. I said well that will be fine but I would really like to read it to you if I may. She then said ok. I read just the most inmortant part. She then said " I have never heard of them asking for 3 yrs of documented drs weight supervision, unless your husband employer put it into the policy". She said probably what they are going to request is that you see a dr for a 6 month period like most have to do, Then she said but I would really have to see the fax first to really know what they are saying. So send me the fax she said. I then told her that I was sending away for all my records because I felt that there had to be more info that I can send to the insurance company about my 10 years of diet history. This is what she says to me. " this is the way it works..... when a person comes to see a doctor at his office, say you come into the dr for a cold. But during the cold the dr notices that you have lost 50 lbs since last time you were in the office. He may say something and the two of you may talk but when he makes his notes about his time with you he will only put in there what he treated you for not everything you talked about so you can send for your records but we checked them and found what we thought was the best stuff to send them" Do you understand what I am saying she ask. I told her yes and then she said she would read the denial letter and give me a call when she finds out what the next step is and she reminded me to send the letter by fax.

Ok so I send it and 4 hours later I check to see if they got it and of course they did not get it , but my end showed they did. So I had to send it again and call them again. They finally said they got it. So I am going to give her until Friday morning to call me then I will call her and if she does not have no info for me by then I will begin to send away for my records and start my own case. I have had several people tell me it is my responsible to get this approved. So I am just going to wait and see what they come up with.

[armywife2aerial]

you know i read all of this and I have UNHC and this worrys me for what ever reason. im my own case. Do you have this plan through the empire plan? when i go to my doctors office they tell me to not stress myself with calling the insurace company a milliane times to stop worrying and they will take care of everything its there job. and i have to let them do there job and they will get me appoved the surgen even told me stop worrying we will take care of it were good at this stuff. but now ya got me worryed lol

i wish you so much luck with everything and im shore you will be on the losser bench before ya not it. remember its just another bump in the road and were are fighters

[MsVickie]

Breathe ladies..............Just breathe.......... Im sure yall are gonna be ok with this. PATIENCE........PATIENCE....... are yall ready to smack me yet? LOL Im sure things will work out like they should for both of yall. Just do what they ask for..... and let them do the work. Let that office hash it out with the insurance company before taking it upon yourself. Im worried your getting to stressed over this. I good friend of mine told me one time to pick my battles and dont fight the war until you have to. So pick the battle right now, and hope the WAR dont come. You both need a break from this stress. Do somthing fun this weekend and put this outta your mind until you have to deal with it again.

[MsVickie]

Donna,

If they make you do that 6 month supervised diet be thankful they offer you that chance. a lot on these boards had to do it. I was lucky. When i mentioned the possibly of thinking about having this done 3 years ago to my Dr. she said OK lets start charting this now. At some point they will want a supervised diet by a physician started and we can start that now.

Its not over... for you and you know that. Please don't get stressed over this, or should I say anymore than you are. Its not good for your body. Stress effects a lot of things. When i say breathe I mean breathe. Sit back relax and think about something else. Its gonna be OK. Keep your faith. I will be going out of town this weekend camping. I leave Friday and wont return until Monday. So don't think I just run off on you OK? Its my stress relieving weekend. I haven't had time off from my job since last September and Im long over due.