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.