Why UHC Denies Bariatric Surgery
BMI does not meet threshold
Supervised weight loss program not completed
Psychological evaluation not documented
Comorbidities not adequately documented
Know UnitedHealthcare's Criteria
UHC uses InterQual criteria and their own Clinical UM Guidelines (CG series). Medical directors are typically accessible for P2P within 5 business days.
Key policies to know:
- Requires eviCore for MSK and advanced imaging prior auth
- Clinical UM Guidelines (CG series) are publicly available online
- Prior auth through Optum/UHG portal
- Known for strict step therapy requirements on biologics
UHC's Specific Approach to Bariatric Surgery
Applicable Policy
UHC Clinical UM Guideline CG-SURG-38 (Bariatric Surgery)
How UHC Typically Denies This
UHC requires a 3-6 month supervised weight management program with monthly physician visits, dietary counseling, and documented progress. The program must be completed within 2 years of the surgery date.
Your Strategy for This Payer
The most common denial is incomplete supervised weight loss documentation. Ensure every monthly visit is documented with weight, dietary compliance, and behavioral modification progress. UHC also requires psychological clearance.
Key Phrase to Use on the Call
"The patient has completed [X] months of supervised weight management with monthly documented visits per CG-SURG-38, along with psychological clearance and nutritional evaluation, meeting all pre-surgical requirements."
Building Your Medical Necessity Argument
Document BMI >= 40 or BMI >= 35 with comorbidities
Show completion of 3-6 month supervised weight loss program
Include psychological clearance and nutritional evaluation
List comorbidities with supporting clinical data (A1c, BP, sleep study)
P2P Call Tips for UHC
Reference UHC's own Clinical UM Guideline number (e.g., CG-SURG-71)
UHC medical directors respond well to InterQual criteria language
Be specific about which InterQual subset applies
Have the CG policy number ready -- shows you've done your homework
Guidelines to Reference
- ASMBS/IFSO Guidelines for Bariatric Surgery
- NIH Consensus Statement on Bariatric Surgery
Relevant CPT Codes
Specialty: General Surgery
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