Now that diabetes is on the rise and obesity is recognized as an illness, it is possible that getting health insurance companies to cover weight loss surgery will become a little easier. Such thinking is hopeful, so we must wait and see what happens. Until then, if you are considering weight loss surgery it will not hurt to give some thought to the bariatric surgery insurance appeal process and how to write a bariatric surgery insurance appeal letter.
Causes for Bariatric Surgery Insurance Denial
It is no secret that insurance companies deny claims. Decisions can be based on profit motive, and denial of services is not unusual. A request for gastric bypass can be denied if you provide information that is not accurate or if gastric bypass surgery is not covered under your plan.
In addition, your request for gastric bypass surgery can be denied if you have a pre-existing condition, if weight loss surgery is not medically necessary, or if the weight loss surgery is experimental.
If you are denied, you have the right to contest the decision and write a bariatric surgery insurance appeal letter.
Bariatric Surgery Insurance Appeal Process
The bariatric surgery insurance appeals process can be time consuming and challenging.
You will first need to get the reason for your weight loss surgery denial in writing from the health insurance company. It should include specific information such as the criteria used for the review and the name and credentials of the person who issued the denial for your weight loss surgery.
Your insurance company will have guidelines for an appeal, so contact them for the information and follow the protocol.
Seek help from you bariatric surgeon‘s office. They should be able to expedite the process.
Compose a detailed insurance appeal letter for weight loss surgery and send it to your insurance company. Begin keeping records of all correspondence with your insurance company. Pursue until you get a final answer in writing from the insurance company regarding your status and your appeal letter for weight loss surgery.
Bariatric Surgery Insurance Appeal Letter
You can begin by contacting your bariatric surgeon‘s office to see if they have a sample bariatric surgery insurance appeal letter. Some bariatric surgery practices actively help with the appeals process while others do not. If your surgeon’s office does not, then find a bariatric surgeon who will fight for you!
When you write your bariatric surgery insurance appeal letter you must include your full name, your policy number, the treatment description, the treatments dates, and the total charges.
You should document the reason you were given for the bariatric surgery denial and your intention to appeal that denial.
You will need to document the records that the insurance company used to support their denial of your bariatric surgery and copies of the medical opinions supporting the denial. Ask, also, what records you will need to provide in order to get approval for your weight loss surgery.
Finally, you must provide your contact information.
Exclusion of Bariatric Surgery as a Covered Benefit
Your health insurance plan is provided by your employer. Thusly it is your employer who selects the health plan and what benefits, such as bariatric surgery, are covered. So the best way for you to get your bariatric surgery covered if it is excluded from your health plan is to discuss this with your employer. They are the ones who are the determining factor on benefits, not the health insurance company.
I spoke with a bariatric surgery patient who works for a health insurance company about why some employers exclude weight loss surgery as a covered benefit. “Many employers don’t realize they can see a reduction in employee sick days and an increase in employee productivity when bariatric treatment is an option. They are just looking at how expensive this “elective surgery “ is.” Pro tip: This is another reason why it is important to review the medical benefits package beforehand when you are choosing a new job.
How do you file an appeal for bariatric surgery with your employer? Well, the insurance company representative can file a complaint on your behalf if you do not wish to discuss this with your Human Resources Department. The appeal pretty much states “hey your employees need this coverage.”
Denial of Appeal for Bariatric Surgery
Depending on the type of health insurance you have, you may be able to file a second appeal if your first appeal is denied. A possible option is a review of the appeal by an independent board of experts.
If you are denied yet again, you can seek legal recourse. There are a number of law firms that specialize in bariatric surgery denials.
Living larger than ever,
My Bariatric Life