Jennie1980
Active Member
- Joined
- Apr 21, 2016
- Messages
- 35
I have United HealthCare Community Plan as my secondary insurance. UHC is my state's Medicaid. My primary excludes all bariatric surgery. In August 2015 I started my journey by attending a seminar. The office of my surgeon suggested switching from Blue Care to United HealthCare as they said it was easier to get approval with UHC. And frankly, they pay better. I had just missed open enrollment. I'm a lightweight but I'm very sick. I have 5 of the 6 comorbid conditions that my insurance considers for approval. I began doing the required 6 months of supervised dieting in anticipation of switching to UHC in July of 2016, during open enrollment. I did everything required of me by that time and made the call, got switched and was told the change would be effective September 2016. Submitted and was approved. In the meantime the office I am using raised their fee for non covered services. I was saving up. Meanwhile, my approval expired in December 2016. I didn't know this until I was about to pay the fee. No big deal, I was approved once on the same exact information. Well, they denied me in February. I appealed and they denied me again. They listed the reason as not medically necessary because no information was sent that told my BMI, listed any comorbidities, stated I had done the 6 months dieting and had the psych eval. Non sense. So we appealed and sent all of that information again. I was denied again. The said that even though I have the required BMI that I needed to send 6 months supervised dieting, psych eval, and proof of comorbidities. Only this time they listed very specific information such as proof of my blood pressure and that I'm taking medicine for it. They acknowledged that I use a CPAP but they want they the actual report and listed a certain number they require the AHI to be. I guess my primary doctor's word isn't good enough. She has sent them a very detailed letter regarding all of my comorbidities and my dieting. I've never seen my actual sleep study report. I have no idea if I met the requirements as I don't know what my AHI number is. UHC pays for my blood pressure medicine, my cpap supplies, my metformin, my cholesterol medicine and my multiple musculoskeletal medicines. I'm just stunned that they're giving me such a hard time. My surgeon's office has never seen anything like it. It's extremely frustrating because I've been working at this for a long time and I gathered very detailed information about what they required for approval. Then I went down the check list and accomplished/proved everything they were expecting of me. I'm at a loss. Of course I will keep fighting but I feel like I'm being unfairly targeted. Have any of you all had any experience with anything like this? I'm wondering now if maybe I shouldn't drop the appeal process, wait for the time to lapse for that and then just resubmit a new request. The surgeon's office says that will take months. But when I suggest that Dr. Boyce just call in and do and peer to peer review, they act like I'm asking him to donate his kidney to me. It boggles my mind. They let thousands of dollars slip through their hands over $1,500. That's odd to me. And even though I do believe they sent the necessary paperwork all along, that they aren't very aggressive in getting they he job done. My BMI is 36. I have musculoskeletal diseases made worse by my weight. I have sleep apnea. I have ridiculously high cholesterol and the medicine hasn't helped over a 2 year period. I'm pre diabetic and on metformin. The insurance office told me before that if I was on medicine for pre diabetes that it counts as type 2 diabetes. I have high blood pressure and take medicine for that. All of which UHC pays a portion of these medicines and treatments. My letter from my primary doctor was remarkably well done. I did the 6 months dieting. I did the psych eval. That's about all I can think of right now that they required. The only comorbid condition they list that I don't yet have is heart disease. They told me in the beginning a bmi of 35 with TWO comorbidities. Now they say only one is required. Apparently my 5 are not serious enough. And I don't know if they don't realize they approved me a few months ago or if they're just enjoying effing with me. Any thoughts or suggestions?