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April 25, 2006

Will my Insurance pay for my Surgery?

Insurancehelp_1 I have only heard bad experiences with this topic. Insurance companies just don’t understand the cost on the long term of having to deal with a morbid obese customer. In my particular case, I had diabetes, sleep apnea, hypertension, and you name it, all obesity related illnesses.

Just like in current politics, my Health Insurance (NHP in South Florida) made a preemptive strike a few years ago, by sending me letters informing their customer base that they would never pay for WLS. This way before I even considered the operation. So, from the beginning I knew it would be hard to deal with.

I tried a few letters back and forth, but at the end, and based on the feedback I was getting from other NHP members, it was a fight not worth fighting. So I decided to open my own pocket.

A few months ago I was presented the ebook called “Weight Loss Surgery Insurance Secrets” written by Craig Thompson. I read it and found it overwhelming interesting and informative on how I could (have) fought my way so my insurance company could pick up the tab. But it was to late for me.

Wlsinsurance160x210_2 I have been asked too many times about insurance companies and their WLS policies… So my advice is, get Craig’s Book, and continue to read ahead:

Insurance Companies exist because of the money, not your health

Insurance coverage for the Gastric Bypass procedure depends on a determination by your primary care physician, surgeon or specialist that gastric bypass surgery is medically necessary to reduce significant medical risks to your life. In general, your insurance carrier will also require (among other specific documentation):

  • A thorough medical history
  • A detailed diet history over the past two consecutive years under medical supervision
  • Current height, weight and BMI (body mass index)
  • A list of all co-morbidities that are or may be caused by your morbid obesity
  • A psychological evaluation/clearance must be included in a letter of medical necessity written by your primary care physician and provided to the Obesity Surgery Specialists for submission to your insurance company.

What if my insurance denies my claim?

If your insurance denies coverage for the gastric bypass surgery, don't give up hope. In many cases, providing additional information in the form of an appeal letter could result in your denial being overturned. If your insurance carrier continues to deny coverage, you may consider seeking legal assistance. Insurance companies will often relent to avoid confrontation.

Additional Information about insurance coverage for WLS

Most insurance companies follow the recommendations of the National Institute for Health when they set up their guidelines to qualify for surgery. However, some insurance companies have offered “exclusion” to employers when contracting for an insurance policy.  This means that your employer may have elected to not cover the medical treatment for obesity or morbid obesity.

Some insurance companies will require documentation of a history of morbid obesity.  You can easily obtain these records from any physician you have seen in the past.

This includes your primary care physician, internal medicine physician, gynecologist, pediatrician, or any other physician who has kept track of your weight.

Insurance companies will not accept a summary letter from your physician…they will need the actual office visit records. If you have taken any medications that were prescribed by a physician to assist in weight loss, the insurance company will want to see these records.

Records from Weight Watchers, Jenny Craig or other diet programs are generally not accepted for documentation of attempted weight loss, but if you can get these records they may be helpful as supporting documentation.

Some insurance companies will require pre-operative evaluation and clearance for members who have a history of severe psychiatric disturbances or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications.

All HMO insurance companies will require a referral to the treating physician.  They may also require that you stay within a certain list of physicians.  You should check this out with your primary care physician early in the process.

Ask questions

Since you probably still have a big behind (yeah, that is why I write this and why you are here, no?) you have to be a real “pain in the butt”. Call them, write to them, and regardless of the initial policy, ask the company to send you their policy bulletin or treatment guidelines regarding coverage.  This document will tell you everything your carrier requires for coverage.  Pay particular attention to any requirements for diet history.  The lack of documented history is the number one reason requests for this surgery are denied.


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