At some point, after you have spent a considerable amount
of time exploring the option of weight loss surgery, you will need to determine
how to pay for the procedure. A growing number of states have passed legislation
that requires insurance companies to provide benefits for weight loss surgery for
patients that meet the National Institutes of Health surgical criteria. And while
insurance coverage for weight loss surgery is widespread, it often requires a lengthy
and complicated approval process. The best chance for obtaining approval for insurance
coverage comes from working together with your surgeon and other experts.
Here are some of the key steps you should take to obtain insurance coverage for
weight loss surgery:
- Read and understand the "certificate of coverage" that your insurance company is
required by law to give you. If you do not have one, consult your company's benefits
administrator or ask your insurance company directly.
- You may be required to start with your primary care physician. In some cases, he
or she is the only one you can ask for a referral to a qualified bariatric surgeon.
Even if you are not required to get a referral, it is a good idea to have the support
of your primary care physician.
- Before visiting the bariatric surgeon, organize your medical records, including
your history of dieting efforts. They will be valuable documents to have at every
stage of the approval process.
- Document every visit you make to a healthcare professional for obesity-related issues
or visits to supervised weight loss programs. Document "other" weight loss attempts
made through diet centers and fitness club memberships. Keep good records, including
receipts.
- If your surgeon recommends weight loss surgery, he or she will prepare a letter
to obtain pre-authorization from your insurance company. The goal of this letter
is to establish the "medical necessity" of weight loss surgery and gain approval
for the procedure. The following information is generally included in the pre-authorization
letter:
- Your height, weight and Body Mass Index and any documentation you might have as
to how long you have been overweight.
- Simply describing your condition as "morbid obesity" is not enough. A full description
of all your obesity-related health conditions, including records of treatment, a
history of medications taken and documentation of the effects these conditions have
had on your everyday life is necessary.
- A detailed description of the limitations your excess weight places on your daily
activities, such as walking, tying shoes, or maintaining personal hygiene.
- A detailed history of the results of your dieting efforts, including medically and
non-medically supervised programs, medical records and records kept of payments
to and meetings attended with commercial weight loss programs.
- A history of exercise programs, including receipts for memberships in health clubs.
- Ask your doctor to include information from medical journals regarding the effectiveness
of weight loss surgery, particularly information showing the control or elimination
of obesity-related health conditions.
Thirty days is the standard time for an insurance provider to respond to your request.
You should initiate a follow-up if you have not heard from your insurance company
in that time.
The Appeals Process
Even if your initial request for pre-authorization is not approved, you still have
options available. Insurers provide an appeal process that allows you to address
each specific reason they have given for denying your request. It is important that
you reply quickly. It is also recommended that, at this point, you enlist the help
of an experienced insurance attorney or insurance advocate to properly navigate
the complexities of the appeal process. Some insurers place limits on the number
of appeals you may make, so it is important to be well prepared and that you clearly
understand the appeal rules of your specific plan.
