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.