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.
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.
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:
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:
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.
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.
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:
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.