Each insurance company has its own criteria for bariatric surgery, and policies change frequently. We will work with your insurance company on your behalf and submit all required information to expedite their approval process, so you'll know in advance what is covered.
First we will prepare a letter to establish the "medical necessity" of weight loss surgery and obtain pre-authorization from your insurance company. We will need some facts and records from you to prepare this letter, such as your height, weight, body mass index and any documentation proving how long you have been overweight. Insurance companies will not accept "morbid obesity" as enough to establish medical necessity. They require a full description of your obesity-related health conditions, including documentation of the effects they've had on your everyday life, records of treatment, and medication histories.
We will need a detailed history of your dieting efforts and results with medically and non-medically supervised programs, including medical records, and payment and attendance records with commercial weight-loss programs. We will also need a history of your exercise programs, including health club membership receipts.
Lastly, we will need a letter from your general physician diagnosing you as morbidly obese and stating that you are a candidate for bariatric surgery. Your physician should also state that he or she has supervised you in diet and exercise attempts that have not significantly helped.
Advantages to Choosing Our Practice:
- We have bariatric insurance specialists on staff
- We “Case manage” the approval process and review each case weekly
- We understand insurance plan language
- We won’t take no for an answer, if you have the benefit and meet criteria
- We have an “Appeals” expert
- We have a 99% approval rate for patients with bariatric surgery benefits
What is an “Exclusion?”
Unfortunately, many policies have “Exclusions” written into them regarding gastric bypass and lap band surgery. This means that even though the treatment may be “Medically Necessary”, it is not a covered benefit. Industry leaders are working diligently to make national changes regarding coverage and Medicare’s announcement of national coverage may help the push for all insurance companies to provide coverage. If your policy has an “Exclusion”, there is little that can be done. There are some options you may want to evaluate:
- You may have to change policies, if this is an option, during open enrollment from the HMO to the PPO, although there is no guarantee that the other policy will cover obesity surgery.
- You may have to change to a spouse’s policy.
- You may have to finance or privately pay the surgery (please call our office for details).
The surgical treatment of morbid obesity is a covered benefit under many insurance policies. Coverage depends on what type of policy you have and the terms within the policy. Each insurance policy can vary greatly, even if different policies are issued by the same insurance company. Your employer and the insurance company determine the benefits available to you.
