Insurance Issues Related to Morbid Obesity

How do I know if my insurance policy covers weight loss surgery?

You can call your insurance company and ask if weight loss surgery is covered for the treatment of morbid obesity. The CPT codes are: lap band 43770 and open gastric bypass CPT 43846, 43847 and Laparoscopic Gastric Bypass CPT 43644 and 43645. If it is not covered, we are working with local and national banks that may be able to assist you with affording the surgery.

Why does it take so long to get insurance approval?

After your initial consultation is completed and you have completed your insurance’s requirements  (such as sleep study and psychological exam), we will send a letter to your insurance carrier to start the approval process. In the meantime, you will work on completing the other medical tests and consultations necessary to make sure that you are an acceptable operative candidate. The time it takes to get an answer usually varies from about 1-6 weeks if your work-up is complete. If may take longer if your pre-operative work-up is not complete. If we receive notification of approval from your insurance company, we will notify you at that time. If you have not heard back from us, it may be helpful for you to call the claims service of your insurance company about a week after your letter is submitted and ask about the status of your request.

How can they deny insurance payment for a life-threatening disease?

Payment may be denied due to a specific exclusion in your policy for obesity surgery or "treatment of obesity." Such exclusion may be appealed when the surgical treatment is recommended by your surgeon or referring physician as the best therapy to relieve life-threatening obesity-related health conditions, which usually are covered. Insurance payment may also be denied for lack of "medical necessity." A therapy is deemed to be medically necessary when it is needed to treat a serious or life-threatening condition. In the case of morbid obesity, alternative treatments - such as dieting, exercise, behavior modification, and some medications - are considered to be available. Medical necessity denials usually hinge on the insurance company's request for some form of documentation, such as 1 to 5 years of physician-supervised dieting or a psychiatric evaluation, illustrating that you have tried unsuccessfully to lose weight by other methods.

What can I do to help the process?

Gather all the information (diet records, medical records, medical tests) your insurance company may require. This reduces the likelihood of a denial for failure to provide "necessary" information. Letters from your personal physician and consultants attesting to the "medical necessity" of treatment are particularly valuable. When several physicians report the same findings, it may confirm a medical necessity for surgery. When the letter is submitted, call your carrier regularly to ask about the status of your request. Your employer or human relations/personnel office may also be able to help you work through unreasonable delays.