Monday November 24, 2014
The Success of Weight Loss Surgery
Research has shown that weight loss surgery coupled with behavior modification to encourage a healthier lifestyle will result in weight loss and a reduction of many obesity related health conditions.

Bariatric Surgery Insurance Appeal

Appealing a Medical Necessity Denial - Patient's Letter

Weight Loss Surgery Insurance

Be persistent - The appeals process can take a lot of work, but don't give up!

If you requested pre-authorization for bariatric surgery and receive a denial, APPEAL. As there is usually a time limit to respond, it is important to appeal within a timely manner, but it is also important to respond effectively. When appealing, write a letter that is factual and persuasive, yet pleasant and polite. Keep in mind your goal - approval for weight loss surgery.

Your appeal letter should include:

  • Patient Identification - information used to identify your case, such as your name, policy number, group number, claim number
  • Reason for denial - restate reason for denial as explained in denial letter
  • Brief health history - patient statement of history with obesity, health conditions, previous weight loss attempts, and why bariatric surgery is a necessary treatment
  • Information to correct errors - if it appears the denial was made because of an error, state the correct information, such as wrong surgery or procedure coding error
  • Why you disagree with denial - tell the insurance company why you disagree with their decision, whether due to incorrect or incomplete information, and provide specific, factual information that supports approval of weight loss surgery for treatment
  • Purpose of letter - what you are requesting in your appeal, i.e. that the insurer reconsider the denial and approve coverage for the procedure in a timely manner

Sample Patient Appeal Letter for Bariatric Surgery

(Date)


(Name of Contact Person at Insurance Company)
(Insurance Company Name)
(Address)
(City, State ZIP)

Re: (Your Name)
(Group Number/Policy Number)
(Case Number/Claim Number)

Dear (Name of Contact Person at Insurance Company),

I am writing this letter to appeal (insurance company name) decision to deny coverage for (name of the specific procedure denied). Based on the letter of denial dated (insert date), this procedure was denied because "(quote specific reason for the denial as stated in denial letter)."

To review my health history, I was diagnosed with (list medical conditions) on (dates). My previous methods of weight loss treatment include (list treatments). At this time, my doctor (name of doctor) believes that (state name of procedure) is medically necessary and will significantly benefit my health. I have also enclosed a letter from my doctor, (doctor's name), that discusses my medical history in more detail.

As you may have based your denial on incorrect or incomplete information, I wanted to provide the following information that shows why I disagree with your denial and why I believe (name of procedure) should be approved.

  • (Provide specific facts to support weight loss surgery and counter reasons of denial, including medical studies, medical articles, and other information that shows that procedure resolves and improves your diagnosis).

Based on this information, I am asking that you reconsider the denial and approve coverage for (name of procedure). My doctor has scheduled surgery for (date). If you need any additional information, please contact me at (telephone number).

Thank you for your time and attention to this matter.

Sincerely,


(Your name)
(Your address)
(Your City, State ZIP)
(Your telephone number)

Tips for the Appeals Process

  • Keep copies of all correspondence you receive from the insurance company, including denial letter(s) and approval letter
  • Make copies of all correspondence you send to the insurance company, including letters, health history, medical files, doctor's letters
  • Keep a written record of all contact and phone calls with the insurance company
  • Send all correspondence to the insurance company via certified mail with return receipt
  • Be persistent! - The appeals process can take a lot of work, but don't give up. Many people have been successful in winning insurance approval for weight loss surgery with persistence and proper documentation.

Consumer Guide to WLS

WLS Insurance

What is an Appeal?

If your insurance company denies your request for coverage of bariatric surgery, you have a right to ask for a review and for them to reconsider the denial and approve coverage. This is an appeal.

The appeals process does not involve courtrooms, lawsuits, judges, lawyers, or arbitration, rather it is a written response that includes the necessary documentation and information in support of the request for treatment.

Bariatric Surgery Payers

In 2012, of the patients undergoing a bariatric procedure, it was paid by:

  • Commercial Insurance 73.90%
  • Government Insurance 22.28%
  • Self-Pay 3.71%
  • Worker's Compensation 0.07%
  • Unknown/Other 0.04%

Source: 2012 HealthGrades Trend Report

  • Weight loss surgery is the only proven treatment for morbid obesity, yet only 1% of the qualifying individuals undergo this treatment.
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