Second denial. Ugh! OK, guys, what's next? Gear up for battle? Give up?

 I don't remember from your posts if UHC says in the fine print that you absolutely must have a 40 BMI or if their language is vague and they are trying to worm out of paying for your surgery.

Is there a way your surgeon can do a peer-to-peer review with a medical director at UHC? That is a good place to start. If your current surgeon will not do it, then find one who will. I hate, and I mean HATE, when office staff are lackadaisical because it doesn't affect them personally.  

So no, don't give up. Fight! Insurance companies are so blind on this. It is much cheaper to pay for surgery now than it is to pay for a lifetime of treatment for comorbidities. RnY cost less than open heart surgery, for example.

And yes, you could gain weight, but I would fight first.

Good luck! I am pulling for you. Beat those *******s into submission.

Edited to add: My surgeon's office coordinator is a sack of stupid. I called my insurance company and talked with the review nurse and got the right info. Then when I told the insurance coordinator what is was and she didn't believe me, I emailed and called the office manager. I made it abundantly clear that I would leave and go elsewhere if she didn't start doing her job and quit giving out misinformation. Suddenly she got it together.

Does your policy state, in writing, that you must have a BMI of 40?  Not 35 with comorbidities?

If that's what the policy says, then there's probably no way to get them to cover it.  Legally, they have to cover whatever your policy says they will cover.

If you have to have a BMI of 40, gaining a few pounds might be a strategy.  But make sure your policy doesn't require you to have a BMI of 40 for several years.  Some require a BMI of 40 for as long as five years before they will cover WLS.

Yep, here is what my first denial letter says:

"Covered person must have a minimum of BMI of 40; Covered Person must have documentation of a diagnosis of morbid obesity for a minimum of five (5) years from a Physician."

What the lady told me on the phone today sounds similar.

OK, if it is as simple as being BMI >40 *right now* in order to even get them to look at my case, I could do that by discontinuing my metformin and loading up on fast food, cookies, and milk shakes (I truly am sorry, body; I know we feel horrid when I do that).

The absolute tragedy in my mind is that I had worked with my PCP from 2008-2009 and went from 282 to 220 lbs (BMI went from 42 to 33 in this time). I quit after stalling for 4 straight months and ballooned back to 270 (BMI 40.5). I returned to my doc from 2011-2012 and went from 270 (40.5) to 248 (37.2). So, it would seem that my efforts to do the right thing and participate in self-initiated physician-supervised weight loss not once but twice have managed to disqualify me.

   

I went ahead and reached out to Lindstrom to get their perspective. My insurance coordinator is out of office until Monday. I will email her to figure out next steps. I think this time it will require a face-to-face.

Do insurance companies ever get to the point where they say, "ok, this is our final answer and you're out of appeal options?" When does that happen?

 

If you are submitting new clinical information with each request, then no, they cannot just slam the door on your appeal. It is only if there is no new clinical information that your appeal process can be exhausted.

What are your comorbids?  I know that every UHC policy is different, but I would call them and ask them why you wouldn't be considered a Class II obese person, as outlined at

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII /UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf /Tools%20and%20Resources/Policies%20and%20Protocols/Medical% 20Policies/Medical%20Policies/Bariatric_Surgery.pdf

This policy was just updated in December of 2012 - maybe the people you talked to didn't get the memo?  Or maybe you have to withdraw your authorization request and start over?  I don't know, but it is worth a try to at least ask these questions.  If you don't get the answers you think are correct, ask for a supervisor.

Good luck!

This is excellent , thanks. 

Here is my question. Based on what I see in my policy/contract, only Class 1's are approved for surgery.

If UHC has issued this document discussing Class II's (which I appear to be), which takes precedence? Based on what this doc is saying, it might be that my contract does. Hmmmm. (sigh) such a tangled web.

Then the question seems to become how to get around contractual guidelines that are more limiting than UHC's own care docs. 

I will keep digging.

It would appear to me that your specific policy would dictate your coverage.  What I linked to was UHC's medical policy, which would explain more thoroughly company-wide definitions, etc.  But, it never hurts to ask. 

A lot of insurance companies will allow certain policies to have gastric bypass surgery if they meet certain criteria, while other policies specifically exclude gastric bypass.  It seems to me, without having read your specific policy, that your policy covers an in-between approach.  Who is your policy through - your work?  If so, then your company (HR?) was the one that negotiated that only Class I obese can have the gastric bypass surgery.

Sorry I can't be more helpful.  Before giving up, you might want to contact an attorney who deals with medical insurance issues on the patient side - they might be able to tell you whether you can fight or not.

I have Medica / Untied Health Care -  I was totally freaked out because like you I had gone up and down over the years......I pulled my medical history from ALL of my doctors - any place where they would have weighed me - from the last 10 years to show the insurance company that for at least 10 years even with my yo-yo'ing up and down I was large and in charge (BMI of 40) for 10 years - they are saying at least 5 - give em more if you have it - then all the ups and downs will count in your favor - I was also a lunatic and made a spreadsheet and became best friends with the gal at the insurance company :-)  You can do it - and I totally would add some weight to my bra to pop me over whatever I needed to be - Good Luck - it will all work out!

THANKS for this great idea, to give them LONGER than 5 years. I will start hunting down med records. And, I'll google lead-lined undies. (giggle!) Did you manage to get them to approve you the first time out or did you have to appeal?

They didn't deny me bit they said no because they needed more info. The chick at my surgeons office was a Morton and didn't send all of my stuff so i made friends with the insurance lady and sent it myself.