Overview of Insurance Coverage for Weight Loss Surgery
Many insurance companies will provide coverage for weight loss surgery if it is considered a medical necessity and the patient meets the National Institute of Health (NIH) requirements for bariatric surgery.
Specific coverage will vary between insurance companies, health plans, and even between states. Some states have passed laws that require insurance companies to cover weight loss surgery if the patient meets the NIH health criteria. Some insurance companies will cover either a portion or the complete surgery cost as long as the individual meets certain patient criteria and the surgery is medically necessary because of life-threatening conditions caused by morbid obesity. Some insurance companies, however, may specifically exclude obesity surgery for any reason.
Even among insurance companies that provide coverage for the weight loss surgery cost, surgery benefits will usually not be considered unless other weight loss methods have been attempted. A request for pre-authorization often requires prior patient participation in a medical weight loss program under the supervision of a doctor with documented weight loss attempts. Some insurance companies require only a six month history, while some insurance companies want to see a one to two year history. Other weight loss attempts and weight loss history prior to that time may be requested as well.
NIH Requirements for Weight Loss Surgery
The National Institutes of Health (NIH), a division of the US Department of Health and Human Services, is considered one of the world's foremost medical research centers. The NIH has set patient criteria for weight loss surgery which states that eligible patients should have a BMI of 40 or higher (morbidly obese) or a BMI of at least 35 with co-morbidities (obesity related health conditions) such as diabetes, sleep apnea, heart disease, high cholesterol, or hypertension (high blood pressure). Eligible patients must also have attempted and failed at previous weight loss efforts and need to pass a psychiatric evaluation to be recommended for weight loss surgery.
Letter of Medical Necessity
Most insurance companies require a Letter of Medical Necessity for bariatric surgery pre-authorization. A Letter of Medical Necessity is a statement written by the patient's doctor detailing a patient's health condition and why weight loss surgery is necessary. It often lists the patient's weight, body mass index (BMI), how many years the patient has been overweight/obese, prior attempts to lose weight, participation in a medically supervised weight loss program, and obesity related health problems.
Medically Supervised Weight Loss Program
Many insurance companies will not consider a request for weight loss surgery unless a patient has previously participated in a medically supervised weight loss program. This type of weight loss program includes diet, exercise, or medication for weight loss which is monitored by a doctor. The purpose of this requirement is to show a patient's efforts at weight loss and that the patient is willing to make the necessary dietary and behavioral changes for bariatric surgery.
Helpful Documents for Insurance Approval
In addition to the Letter of Medical Necessity written by your doctor, there are many documents you should include with your insurance request to improve the likelihood of getting surgery approval. Helpful documentation includes all diet records, medical records, medical tests, records for medically supervised diet attempts, receipts for exercise equipment, gym memberships, or diet programs such as Weight Watchers or Jenny Craig, and any other documentation that shows your attempts at weight loss over the years.
Appealing Insurance Denials for Bariatric Surgery
If you submit a request for pre-authorization of weight loss surgery and receive a denial from your insurance company, it may be discouraging but it can be appealed. Many denials are based on factors which can be worked out, such as missing medical history and weight loss documentation. If you receive a denial, contact the insurance company to find out the reasons for the denial and what information they need to grant bariatric surgery insurance coverage.
Many individuals have followed up with their insurance company to determine the reasons for the denial, then met those requirements, submitted an insurance appeal letter with the requested information, and succeeded at having their denial overturned. The insurance company may not make the process easy on you, but if you continue to work on your own behalf you may eventually be granted insurance approval for bariatric surgery.
While dealing with the insurance company can be overwhelming, you should not have to handle the insurance requests on your own. Your bariatric surgeon should be both experienced in dealing with insurance companies and willing to work on your behalf. If you and your doctor are not able to convince the insurance company to pay for weight loss surgery, you may want to consult with Lindstrom Obesity Advocacy (www.wlsappeals.com), formerly known as Obesity Law & Advocacy Center, for help and advice.
Appealing Insurance Denials Citing Lack of Medical Necessity
Insurance requests for bariatric surgery are often denied because the insurance company cites a lack of medical necessity. To be considered medically necessary, the insurance company needs evidence to support this claim - such as documentation showing that other weight loss methods have already been tried and why bariatric surgery is necessary to treat a serious or life-threatening disease (obesity or type 2 diabetes). Bariatric surgery is considered a last resort treatment and will not be covered unless other methods of weight loss have been exhausted.
Lack of proper documentation, such as medical records for one to five years of physician supervised dieting, psychiatric evaluation, or a letter from your physician stating your obesity co-morbidities, can result in a medical necessity denial. Make sure you provide the insurance company with the information required to support the claim that bariatric surgery is medically necessary.
Appealing Insurance Plan Exclusions for Weight Loss Surgery
In addition to treating obesity, bariatric surgery is now considered an effective treatment for many metabolic diseases and conditions including type 2 diabetes, hypertension (high blood pressure), high cholesterol, obstructive sleep apnea, and non-alcoholic fatty liver disease. Even if your insurance plan has an exclusion for "obesity surgery" or "treatment of obesity" it may cover treatments for the above-mentioned health conditions. If you have any of these obesity co-morbidities, the appeal would be based on the recommendation that bariatric surgery is the best method of treatment for these listed diseases, which are usually covered health conditions.