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Help! UHC denied due to no 3 year history

Discussion in 'Nebraska' started by Customademe, Aug 2, 2014.

  1. Customademe

    Customademe Member

    Messages:
    12
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    6
    OMG!

    Someone has got to help me! I've gotten all the way to getting my information submitted to the insurance company by my doctor, only to have my insurance company hit me with: "you have to have a documented history of failure to sustain weight loss with medically supervised dietary and conservative treatment for at least 3 years" stuff.

    I had a stroke 3/2012 and prior to that I just didn't go to the doctor other than for an annual DOT physical required by my former employer. I didn't have/couldn't afford insurance at that time. Since the stroke, I had to see the doctor, physical therapist, and stroke counselor.

    I asked what I thought were all the right questions of eligibility/requirements for WLS, been through the 6 months of eating modifications, medical/psychological testing and was just waiting for the approval so I could get my surgery date...then BAM!

    I know there is someone else out there who has been through this with United Health Care or some other insurance company. I am so depressed and my body is killing me to get this weight off!

    Please HELP!
     
  2. Cheyenne

    Cheyenne Active Member

    Messages:
    2,327
    Trophy Points:
    30
    Surgery Type:
    gastric bypass R-N-Y
    Surgery Date:
    June 24 2013
    Start Weight:
    392 - 358 at surgery
    Current Weight:
    165
    Goal Weight:
    150

    I have Untited Health Care and had my bariatric surgery 13 months ago. I had to meet the requirements, 6 months supervised diet by my Primary Care doctor, certain health tests, cardiac and pulmonary, mental evaluation from my specialists. I was approved very quickly. I live in Virginia. UHC does have different health care plans, my plan is the Federal Goverment MDIPA plan.

    Because you have had a stroke, If I were you I would get your specialist you had for your stroke, or your primary care doctor, give you a letter that you need this bariatric surgery ASAP because it will cut down your risk of having another stroke. Weight has a significant impact on our blood pressure and other bodily functions. Also this 3 yr old failure to lose weight rule must be something very new because they hadn't told you about it when you asked for the criteria to get the surgery. Is this new rule actually in writing or is it something just thought up by someone at UHC trying to save the company money. I would get a letter saying you desperately need this bariatric surgery for your health, and you need appoval now. Then resubmit your request for surgery and if that fails you can appeal your denial.

    Good luck to you, let us know how this goes.


    Cheyenne
     
  3. fuww57

    fuww57 Member

    Messages:
    132
    Trophy Points:
    16
    Surgery Type:
    Gastric Sleeve
    Surgery Date:
    Aug. 23, 2013
    Start Weight:
    362 lbs.
    Current Weight:
    173 lbs.
    Goal Weight:
    175 lbs.
    If you haven't already done so, consult with the person in your surgeon's office who deals with the insurance companies. Mine was great in giving advice. She saved me a lot of grief when I received officious letters from my insurer.
     
  4. Customademe

    Customademe Member

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    Thank you so much for your response. As a matter of fact the person in the surgeon's office emailed me on Friday and said she would call today, but she didn't call. I will be calling her in the morning.
     
  5. Customademe

    Customademe Member

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    I am so grateful for your response and I have begun the fight. It really helps to come here and chat with people who understand what I'm going through. I know my parents mean well when they say, " You lost it before, just do it again." but they also see that I regain more than I lose.
     
  6. Cheyenne

    Cheyenne Active Member

    Messages:
    2,327
    Trophy Points:
    30
    Surgery Type:
    gastric bypass R-N-Y
    Surgery Date:
    June 24 2013
    Start Weight:
    392 - 358 at surgery
    Current Weight:
    165
    Goal Weight:
    150

    Dont let the Insurance company get you down. I really think you should be able to win this fight. If I were you I would stress over and over that you could have another stroke while waiting 3 yrs to have the bariatric surgery and that just is not an option. Weight affects your blood pressure, heart, and circulation and surely it is a great risk factor for your health. Surely insurance should realize that it would be a great benefit to them for you to get healthy.

    Your parents are probably afraid of their child having an operation. Just let them know that bariatric surgery is something you are set on doing. Explain the benefits to them. Having a laparoscopic bypass is less invasive and so much safer than the way they use to operate. Healing is fast and the pain isn't bad at all.

    I hope this works out for you. :) Again, wishing you the best of luck!


    Cheyenne
     
  7. Customademe

    Customademe Member

    Messages:
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    More bad news. I spoke with the person in the surgeon's office who usually works with the insurance company and she was not cooperative. She said that at the time of the denial, the doctor was contacted and asked if she would like to speak peer-to-peer with those that made the decision and she declined. I found this out from the insurance company rep who also stated that since it has been 15 days since the denial (I told them it was denied 7/24), day 15 would be 8/8, but then he changed it to 10 days, my only recourse was to appeal. I informed him that I needed for them to explain just what the 3 years entailed? Is that 3 consecutive years, is there a limitation on how many years back I can go for this, and where is that information listed in the policy. They couldn't tell me. I asked them, then why am I directed to contact you when you are merely the middle man and can't tell me anything? He apologized and said that I could contact via fax, those that made the decision, asking them to clarify what the denial means for the 3 year requirement and any other questions, so that I could prepare a proper appeal. I was told by the hospital rep that if I am expecting to use data from some 30 plus years ago, that information is on microfilm if at all available and it could take weeks to receive it, not to mention the cost if I don't request it to be sent to my doctor, which I would but I am now questioning their true desire to help me. If that's not enough, I've had nothing but panic attacks since this denial, on a daily basis. A bonus from the strokes. I was working these without meds, but now I think I am going to have to go back on them just to handle all of this. :(

    Enough though about me. Cheyenne, I see that you were scheduled for your surgery in June. How are you doing?
     
  8. Cheyenne

    Cheyenne Active Member

    Messages:
    2,327
    Trophy Points:
    30
    Surgery Type:
    gastric bypass R-N-Y
    Surgery Date:
    June 24 2013
    Start Weight:
    392 - 358 at surgery
    Current Weight:
    165
    Goal Weight:
    150
    P

    I had my surgery the end of June 2013 (a little over 13 months ago) I am pleased with my weight loss. My highest weight was 392 lb but I lost 34 lb while doing my 6 month diet with my Primary Care doctor as per insurance regulations, and was down to 358 lb at the time of surgery. I am down to 195 lb now (I'm currently at a plateau which happens every so often and then I usually drop 10 pounds, hopefully soon) So thats 162 lb from my surgery weight and 197 lb lost from my highest pre-surgery weight. I feel like a new person! I still have a way to go to my goal weight but I'm hoping to reach it by Christmas.

    If I were you I would google the bariatric doctors in your area. You can read on line how your surgeon is rated and how his patients rate him. If your surgeon won't even talk to the insurance people on your behalf then it might be time to look for another surgeon. When I was picking my surgeon I had met with one who wanted all kinds of extra money for protein drinks that he sold out of his office and he charged extra for a nutritionist and an exercise coach and said it wasn't covered by insurance. It would have cost me hundreds of dollars extra every month. Well I went home and got on the internet and found a surgeon through "healthgrades.com" and he was rated 5 out of 5 by his patients and 100% of his patients would recommend him to a friend. I called the office and I was reasured that he did not have any extra out of pocket charges, his nutritionist was covered with his fee which my insurance would cover. He is the type of doctor who will go the extra mile for his patients. Along with being a wonderful surgeon he is a wonderful person. In my opinion you need to find a sugeon who is willing to fight for you. A great surgeon can make all the difference and by great I mean a surgeon who is in his profession to HELP his patients not just make money from them. You could call the surgeons who have great ratings and ask if they will help you. I would bet you will find a surgeon who would be willing to fight for you. They can transfer your tests and records.

    Try to stay calm, it's not at all good for you to be upset, as you know. You just need to find the right doctor to help you.

    Good luck,

    Cheyenne
     
  9. Customademe

    Customademe Member

    Messages:
    12
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    Wow Cheyenne! You should feel like a new person. The person you always were, just revealed in a visual sense. I agree. I will check for another hospital/surgeon under my current insurance. I also am considering signing on with my husband at his open enrollment in September, if they provide the service and have fewer stipulations. It's something to consider. I haven't given up here though. I am still looking into a different surgeon/dr. with my current hospital. I am just getting all my ducks lined up so I have a choice.

    Keep up the good work, you're almost to your goal! :D
     
  10. smiles50

    smiles50 Member

    Messages:
    60
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    10
    Surgery Type:
    gastric bypass
    Surgery Date:
    july 28 2014
    Start Weight:
    243
    Current Weight:
    168
    Goal Weight:
    130
    I belong to the ymca i showed six months of going to water arobics plus i showed 6 months of weight watchers from 2 yrs ago and they passed me.
     
  11. Customademe

    Customademe Member

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    Perhaps that is also a route worth pursuing. I have had many great suggestions from this site. Thank you everyone. I am obtaining lots of documents and will get this surgery approved.
     
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