Bariatric Surgery
Insurance Precertification Requirements
Q&A

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Will My Medical Insurance Cover Bariatric Surgery?

Bariatric surgery is covered by some, but not all health insurance programs, and determining if your plan offers coverage and the type of coverage it provides can be challenging. One insurance provider usually offers multiple plans with each one offering coverage for different procedures or different levels of coverage by the procedure.

The best way to determine the exact coverage offered on your insurance plan is to speak to someone from the insurance company. Each insurance carrier also has a list of requirements that must be met before they will even consider approving bariatric surgery.

As part of the recent healthcare reform, several states have passed laws that require health insurance companies to include bariatric surgery benefits for patients who meet the criteria as described by the National Institute of Health (NIH).

How Can I Find Medical Insurance That Covers Bariatric Surgery?

If you anticipate that bariatric surgery is in your future, you should compare the insurance policies available to you carefully to determine which one would best suit your needs. Pay close attention to detail because within one insurance company, there may be several different plans offered and even if you have coverage on your current plan, details can change from year to year.

Sometimes, consulting with a bariatric surgeon will help you to determine what your current insurance covers or they can suggest a better policy to choose during open enrollment.

Bariatric Surgery Source Online has an information guide that can be used for research purposes when looking for insurance coverage for bariatric surgery. Make sure you complete your due diligence to ensure you have correct and accurate information before selecting a plan or using this guide to check current coverage.

Are There Requirements That I Must Meet For My Health
Insurance To Pay For My Weight Loss Surgery?

Yes, there are requirements that patients must meet before they qualify for bariatric surgery. There are basic requirements that are universal and then requirements imposed by each insurance carrier that vary by company.

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What Are The Basic Requirements To Qualify For Bariatric Surgery?

Individuals must have a doctor’s diagnosis stating

A BMI of 40+

Currently, be at least 100 pounds overweight

A BMI of 35+ and suffer from a weight-related illness such as:

  • Type 2 diabetes;
  • Hypertension (High Blood Pressure);
  • Severe sleep apnea;
  • Or another potential life-threatening medical condition that is obesity-related.

What Bariatric Surgery Prerequisites
Are Required By Insurance Carriers?

In addition to the qualifications listed above, insurance companies also each have their own list of prerequisites and requirements that include:

The patient must have documented proof that they have tried other methods to lose weight but have been unsuccessful. Most companies require that the patients have tried a program that lasted at least six months

Some forms of acceptable documentation of attempted weight loss may include:

  • Gym membership(s);
  • Proof of membership and participation with a structured weight loss program such as Jenny Craig or Weight Watchers;
  • Written records (Journal) of weight loss attempts;
  • Food journals;
  • Attempted medically supervised weight loss programs;
  • Nutritional and dietary counseling visits.

Many insurance companies also require patients to complete psychological testing to ensure they understand the results and long-term requirements of the procedure and clear them of any disorder that may prevent them from being able to make the lifestyle changes necessary.

Proof of attempted (failed) weight loss

What Can I Do To Avoid Being Denied Coverage
For Bariatric Surgery By My Insurance Carrier?

Many insurance companies cover surgical weight loss procedures, however, their pre-authorization and approval process can be complicated and lengthy. Providing all the information required in the correct format can help avoid an extended appeal process after a denial.

If you ensure that you meet all of the insurance carrier’s pre-qualification criteria and can provide clear documentation, you are less likely to run into a denial issue. Here are some steps you can take to help avoid being denied authorization for bariatric surgery.

1. Review your current policy to determine coverage

Every insurance company must provide a “certificate of coverage” detailing the health benefits you and your dependents have coverage for under the plan. (It details the services that are covered and any exclusions that are not covered) If you determine you do have coverage, identify the prerequisites they require so you can ensure you meet them before applying for pre-authorization. If your current policy does not offer the coverage you need, you will either need to plan to change carriers or financially prepare to self-pay for your surgery.

2. Assemble and communicate with your team of doctors

Start with your primary care physician and communicate your desire to have bariatric surgery to them. Some insurance companies require a referral from your primary to begin the process of choosing a bariatric surgeon.

Your primary doctor may also be able to help you with documentation on previous weight loss attempts if you were under their supervision. If you still need to complete these prerequisites, your primary physician can help you get started.

Many times there are medical tests the bariatric doctor will want you to undergo before having weight loss surgery and you will need to work with your primary care doctor on getting these completed.

Next, choose a board-certified bariatric surgeon who accepts your health insurance and set up a consultation. During your consultation, you and the bariatric surgeon will exchange medical information as well as determine which weight loss surgery will be best for you.

Assemble and communicate with your team of doctors

The bariatric surgeon will be instrumental in helping you navigate through the pre-approval process before your surgery. Every bariatric surgeon’s office has a person who handles their insurance which can be a valuable resource in gaining approval for your procedure. The bariatric surgeon’s office has years of experience navigating through the approval process of various insurance companies. Ensuring that the insurance company receives complete and accurate information during the preapproval process can help avoid a lengthy appeal process.

Compile and organize your medical records, any history of unsuccessful attempts at losing weight, and any other information you have that is pertinent, and take it with you to your consultation with your bariatric surgeon.

If you are just beginning to complete the prerequisites to qualify for surgery, be sure that you document every appointment, visit, or anything having to do with losing weight. For example a visit to a dietitian, or a supervised weight-loss program such as Weight Watchers, and dates with times at the gym. It is advisable to keep a journal with as much detail as possible including any receipts for services.

The bariatric surgeon will help you with the submission of required medical documentation necessary during the pre-approval process that clearly demonstrates the medical necessity of bariatric surgery.

3. Submit Your Bariatric Insurance Coverage Request

After meeting with the bariatric surgeon you will more than likely have some tasks to complete to finish fulfilling the insurance company’s prerequisites. Once everything is in order the bariatric surgeon’s office will help you submit the request.

Take the first step on your journey to a healthy life

IBI Healthcare Institute provides an unmatched patient experience and outstanding results. You matter to us.

What Part Does My Bariatric Surgeon’s Office
Play In Obtaining Authorization For Surgery?

The bariatric surgeon will confirm the benefits of your specific policy and all requirements you must meet under your policy guidelines. These requirements and prerequisites will be discussed in detail during your initial consultation. If at any time during your treatment, the details of your insurance coverage change please contact the surgeon’s office as soon as possible.

Once all of the prerequisites have been fulfilled for both the surgeon and the insurance company, the surgeon’s office will submit all the required documentation to the insurance company for review. It can take weeks to months to receive a reply.

Once the bariatric surgeon receives a reply they will move on to the next step. If approved, a surgery date and preoperative appointment will be set up and the process will begin. If the insurance company denies pre-authorization, the bariatric surgeon’s office will review the details with you and prepare to proceed with the appeal process.

Bariatric Surgeon’s Office

Why Does The Insurance Approval Process Take So Long?

Typically, it takes about two or three days for the bariatric surgeon’s office to submit all the documentation necessary to the insurance carrier which starts the approval process. The insurance company will review all of the paperwork and send a letter of acceptance or denial. It can take anywhere from 15 days to several months to get a reply from the insurance company.

Our office will follow up on the submission for approval regularly until we receive an answer. If the process lags, we may contact you and have you call and follow up as well.

If I Am Denied Coverage, What Can I Do To Appeal The Decision?

If the insurance company denies your initial request for pre-authorization for bariatric surgery, you can appeal the decision. Every insurance carrier has a process you can follow to file a formal appeal and you can address each specific reason cited for the denial. Sending a clearly stated reply letter with as much detail and backup as possible is the best course of action. However, some carriers impose limits on the number of appeals that can be made so it is important to find out the appeal guidelines of your plan.

The process of appealing a denial can be lengthy but your chances of overturning a previous denial are greater if you include as much information as possible in your letter of reply and keep the content professional. Your bariatric surgeon’s office can help you compose the letter because they have experience with advocating for patients.

Appeal letters should contain:

  • Your Identification including your name, insurance policy, claim, and group numbers;
  • A summary of the reason(s) for denial using the wording from the denial letter you received;
  • State the reason you are appealing (Clearly explain why their denial is incorrect and provide additional facts. Keep your reasons for wanting the surgery focused on health);
  • Clear up any errors (if your denial was due to an omission of necessary information, incorrect coding, or a matter that can be corrected by providing additional documentation);
  • You may need to include additional health history depending on denial reasons.

Make a file and keep copies of all information you send to the insurance company. Make notes with dates, times, and names of any individuals you speak to over the phone at your insurance company. Being persistent can help get your appeal heard and the denial decision overturned.

What Are My Options If I Do Not Have Insurance
That Covers Bariatric Surgery?

If your insurance plan does not cover weight loss surgery or does not provide adequate coverage for the procedure you are going to undergo, you may wish to change insurance providers during open enrollment. Speak to your bariatric office’s insurance specialist and ask about recommendations for carriers who provide sufficient coverage for the procedure you desire.

Begin to familiarize yourself with the prerequisites required for bariatric surgery and begin working to fulfill them. Keep records of everything so you can submit all of the backup documentation required.

If you are unable to obtain health insurance that covers bariatric surgery you can speak to your surgeon about any financing options they may offer for self-pay patients or consider a lower-cost non-surgical weight-loss procedure such as the Orbera gastric balloon or endoscopic sleeve gastroplasty (ESG).

Take the first step on your journey to a healthy life

IBI Healthcare Institute provides an unmatched patient experience and outstanding results. You matter to us.

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