Important Information Regarding Insurance

When preparing for bariatric surgery, it is important to understand the requirements and benefits of your individual insurance plan. Please check your plan specifically for Obesity Benefits. Do not ask if they cover a certain procedure, just whether they cover weight loss surgery. It is your responsibility to call the number on the back of your insurance card or speak to human resources.

This will be covered in more detail at the seminars.

Please be advised that approval from any insurance company is contingent upon the following and is subject to change:

All insurance companies require a Body Mass Index (BMI) of 40 or higher. A BMI of 35+ may be allowed depending on the number and severity of the patient's related co-morbidities.


Some frequently asked insurance questions:

Is the surgery covered by most insurance?
There are many different levels of coverage for obesity surgery. Here are some key steps you should take to obtain information form your insurance company.
  • Read and understand the "certificate of coverage" that your insurance company is required by law to give you. If you do not have one, consult your company's benefits administrator or ask your insurance company directly.
  • You may be required to start with your primary care provider. In some cases, he or she is the only one you can ask for a referral to a qualified bariatric surgeon. Even if you are not required to get a referral, it is a good idea to have the support of your primary care provider.
  • Before visiting the bariatric surgeon, organize you medical records, including your history of dieting efforts. They will be valuable documents to have at every stage of the approval process.
  • Document every visit you make to a healthcare professional for obesity-related issues or visits to supervised weight loss programs. Document "other" weight loss attempts made through diet centers and fitness club memberships. Keep good records, including receipts.

Why do insurance companies deny approval for obesity surgery?
Payment may be denied because there may be a specific exclusion in your policy for obesity surgery or "treatment of obesity." Such exclusion can often be appealed when the surgical treatment is recommended by your bariatric surgeon 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 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.

What if my insurance company denies approval?
Even if your initial request for pre-authorization is not approved, you still have options available. Insurers provide an appeal process that allows you to address each specific reason they have given for denying your request. It is important that you reply quickly because many options have a very short deadline. You also need to notify your bariatric surgeon as he can make arrangements for a direct communication with the medical specialist of your insurance company which may facilitate the reversal of the initial denial. It is also recommended that, at this point, you enlist the help of an experienced insurance attorney or insurance advocate to properly navigate the complexities of the appeal process. Some insurers place limits on the number of appeals you may make, so it is important to be well prepared and that you clearly understand the appeal rules of your specific plan.