What to Do When You are Denied for Bariatric Surgery Coverage

Posted by Jason Radecke on Mon, Apr 30, 2018

When your insurance company denies your request for bariatric surgery it can incredibly frustrating and demoralizing. We are here to tell you not to lose hope. Do not give up the fight to improve your health. We can help you.

You should approach your denial by specifically addressing the concerns of the insurance company. You will receive a letter stating why you were denied. Follow these two steps to make sure you’ve got everything you need to appeal and change their decision.

Covering your Bases

When you get denied it’s very important to make sure you understand the reasoning behind the decision. Insurance companies hold very strict criteria for qualification, and if you feel you meet all of it and were unjustly denied, look for what factor led to the denial. Your BMI, psychology evaluation, or your personal history of attempted weight loss, which some insurance companies take into consideration, could all be reasons for being denied coverage.

Before you begin the process, your surgeon’s office will determine if you have coverage for bariatric surgery. If you do not, please check into the private pay options that you may be able to do.

If you do not receive insurance through an employer, call your insurance representative or review the policy yourself. The surgeon’s office will also verify coverage and can help you with this process.


Appeal your Decision

If you have coverage and have been denied, then working with you surgeon and their staff in appealing the decision is critical. The surgeon can request a peer to peer review with the insurance medical director and specifically go through the review. Our surgeons are highly successful at getting denials overturned.  

In addition, both the patient and the surgeon should write an appeal letter specifically addressing the denial and why it should be reversed.

In some instances, talking to your HR person is key for this step as they will provide all of the policy information you need to prove your case. You should also make sure to have all of the proper documentation for all of the criteria. This way, when they review your appeal they will see that your claims are backed. An HR person can even go as far as intervening on your behalf to prove you fit the criteria and are covered for the surgery.

If you are not initially successful, do not give up or lose all hope. You can often request what is called a second level appeal or even an outside review by an unaffiliated third party.

Our office has actually had denials overturned two years later. DO NOT GIVE UP.

Continue to work with your surgeon office and explore all possibilities. The Obesity Action Coalition (OAC) may also be able to help. Check out their website for more information.

At Riverside, we are passionate about helping you on your journey of rediscovering your health and well being. Contact us today to set up a  consultation with one of our surgeons!

Tags: Weight Loss Surgery Covered by Insurance

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