In many states, there are laws in place that require
insurance companies to provide benefits for weight loss surgery when a patient
meets the National Institutes of Health (NIH) criteria. However, obesity
surgery patients should still prepare themselves for what is commonly a long
and complicated approval process. The best chance for obtaining insurance
coverage for the cost of gastric banding and gastric
bypass surgery comes from working diligently in cooperation with your
bariatric surgeon and other experts.
The Insurance Approval Process
There several helpful things that you can do to
smooth along the insurance approval process. Following the steps below may be
able to increase your chances of being approved for obesity surgery coverage.
It is important that you read and
understand your insurance company's "certificate of coverage." You
can get it from your insurance company directly or from your employer's
benefits contract.
Get an obesity surgery referral from your doctor. You must have your doctor's full support.
Save all of your receipts and always
keep accurate, detailed records.
Carefully document each visit you make
to doctors and other healthcare professionals for obesity-related issues. In
addition to doctor's appointments, this includes visits to diet centers,
fitness clubs, and weight loss programs.
The Insurance Authorization Process
The lengthy authorization process will begin
when your bariatric surgeon sends your primary care physician a letter asking
him or her to verify the "medical necessity" of your surgery for
obesity. Your doctor can establish this by proving that any of the following
apply to you:
You are morbidly obese with a BMI (body mass
index) of 40 or higher
You have suffered from morbid obesity for at least the past five years
You have attempted, under your
physician's care, other methods of weight loss for at least two years
You have co-morbidities - such as
hypertension, diabetes, sleep apnea, degenerative arthritis, and heart disease
- that constitute medical necessity for obesity surgery
You do not have major psychiatric or
emotional problems
Any of the following that apply to you should also
be mentioned:
You have significant liver, kidney, or
gastrointestinal disease
You have a history of alcohol or
substance abuse
A thyroid test has been ordered and
results will be sent to your surgeon
The Appeals Process
Even if your pre-authorization for obesity surgery
coverage is denied by your insurance company, there is still a chance that you
can receive full or partial coverage for the cost of your bariatric surgery
through the appeals process. During the appeals process, you may contest each
reason your insurance company has given for denying coverage. It is critical
that you submit your appeal quickly in order to have the best chances for a
successful outcome. In some instances it may be helpful to employ the services
of an insurance advocate or lawyer to help you effectively navigate the appeals
process. Your insurance company may limit the number of times that you can
appeal for weight loss surgery coverage, so make sure that you understand the
guidelines set in your "certificate of coverage."
Find a Bariatric Surgery Practice
Schedule an appointment at your local
bariatric surgery center to learn more about the insurance approval process
and financing options.