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How to Appeal Insurance Denial for Weight Loss Surgery

i Jun 6th No Comments by

Bariatric surgery is often a necessary step to save those struggling with morbid obesity that are unable to lose weight without help. While it is considered a last resort for weight loss patients, it is also one of the most effective and life-saving techniques available for addressing the challenges associated with obesity.

Because it is so important in the medical field, many insurance companies cover several forms of bariatric surgery. But many patients have found that the process of getting approved by their insurance provider can often be arduous, and in some cases, even if you qualify, coverage for this important form of surgery is even denied.

What to Do if Your Insurance Company Denies You

There are several reasons you may be denied for your weight loss surgery claim. In some cases, your specific policy may not cover this type of surgery, as not all policies cover bariatric surgery. You will have to check with your insurance provider to see if you have coverage.

Yet most often, the reason for denial is either because the insurance company did not receive all of the paperwork they needed, or they did not feel that it was adequate enough to meet the requirements they have set forward.

If your insurance company has denied a claim that you and your doctor know they should cover, you can try to appeal the decision by writing a weight loss surgery appeal later. These letters should also include any information they ask for, and any proof you have that you meet their approval requirements.

First: Find the Reason You Were Denied in Writing

Before you write your appeal letter, make sure that you have, in writing, the reason you were denied your claim, including the individual that turned down the claim. While every insurance company has a slightly different protocol, they are legally required to provide you with this information.

As soon as you receive a denial, call them with these requests and ask them what their procedures are for an appeal, including what documents they need from you for an approval. This is a critical part of the appeal, as knowing the reason for denial in writing will help you address the issue with the insurance agency.

You may also want to speak with your would-be surgeon for further help. They may be able to expedite the entire process with their involvement. Many will have a template you can use for your letter and may help you fight for this surgery. If yours doesn’t, call other practices and see if there is one in the area who will help you through this process.

After you have spoken with both the insurance company and your surgeon, you can start on your appeal letter. It needs to include:

  • Your full name and contact information
  • The date you wrote and sent the letter
  • Your policy number
  • Treatment description, dates, and total charges
  • The name and full address of your insurance provider

Point out the reasons you requested this surgery:

  • Your age, height, weight, and BMI
  • How long you have been struggling with obesity
  • Past attempts to lose weight via diet and exercise (hard evidence is helpful)
  • The risks of being obese
  • That you are well aware of the risks involved with the surgery

If possible, include any medical records related to your obesity. This could be a diagnosis of diabetes or heart problems. List any co-morbid diseases caused by your weight like high cholesterol, high blood pressure, joint pain, sleep apnea, etc. Do the same for any medications you may be on for these diseases.

Finish with a statement about how obesity is affecting your everyday life. Common issues are:

  • Having trouble walking without running out of breath
  • Fitting into airplane, bus, and theater seats
  • Avoiding social situations out of shame or embarrassment
  • Trouble with normal tasks like tying your shoes or using the bathroom

Finally, include a copy of any of the documents or information that caused your denial, and make sure that you include a copy of your denial letter to prove that you meet the criteria for bariatric surgery from the insurance agency.

After You Send the Letter

Pursue your appeal until you get a formal letter from your insurance company with their final response. Until that happens, document every correspondence you have with your carrier including noting the time and date when phone calls occur and what you talked about.

What to Do if You’re Denied Again

Even after following the above advice, your appeal could still be rejected. You can attempt to request the reason for the denial in writing and appeal again, but some insurance agencies consider a final denial to be permanent. If this occurs, you may need to seek out alternative funding sources, such as:

  • Paying Out of Pocket – Speak with a financial advisor about how you could do this. You may be able to use money from your retirement plan, for example.
  • Take Out a Secured Medical Loan – To receive this type of loan from a bank or credit union, you will usually have to put up some type of collateral (e.g. your home). Unsecured loans for as much as $15,000 are also possible.
  • A Payment Plan Through the Surgeon – Most surgeons offer patients some type of payment plan if their insurance company won’t cover the procedure or if they need help with the amount they are responsible for out of pocket.
  • Permanent Life Insurance Loans – If you’ve accumulated “cash value”, your permanent life insurance policy will help pay for this surgery. However, if you don’t already have permanent life insurance, it could take years to save up the necessary amount.
  • Medical Tourism – Many people travel to Mexico for this type of surgery as the costs are very affordable and the surgeons can be quite good.

Consider each option before making a final decision. The right plan for you may also involve combining two or more.

An initial denial from your insurance company doesn’t mean you can’t receive life-saving weight loss surgery. It may simply mean that you’re delayed. The sooner you appeal, the sooner you may be able to receive the assistance that the insurance carrier has promised.

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