I saw this article in the fall issue of the OAC Magazine and thought it would be beneficial to post for those who have insurance issues. Link to full article (and pdf version) is included.
What to do When You’re Denied (Bariatric) Weight-loss Surgery
by Pam Davis, RN, CBN
To view a PDF version of this article, click here.
*Please note: The terms “bariatric” and “weight-loss” are used interchangeably throughout this article.
Kick, scream, yell, cry, curse and take a deep breath. Kick, scream, yell, cry, curse again and take a few more deep breaths. Of one thing you can be sure, you are not the first person to be denied approval for weight-loss surgery by your insurance; nor will you be the last. While access to care has most certainly improved for many in the last few years, coverage for weight-loss surgery is not standardized and can vary tremendously based on your employer and your insurance plan.
Your Coverage Depends on Your Employer
Frequently, we may be quick to blame the insurer for lack of coverage. It is important to make a clarification. In order to provide coverage for their employees, companies must purchase a “rider” for weight-loss (bariatric) surgery coverage. Self-insured employers (typically larger employers where the money paid for their claims comes from their own pocket) frequently provide weight-loss surgery benefits.
In this circumstance, where the company has elected to provide coverage, the insurance company now applies their standard criteria to those seeking surgery. If the employer has coverage and you meet the criteria on the plan, you are approved, right? Well, not always.
It has been my observation throughout the last several years that many times, it appears as if our patients are denied the first time for a multitude of reasons:
“We did not receive the letter from your primary care physician.” – Rest assured, it was sent.
“We do not have documentation of failed previous weight-loss attempts.” – This too was sent.
“Documentation of weight for one of the previous five years is missing.” – Uh-huh, sure it is.
The good news here is if your employer is self-insured with a bariatric surgery benefit and you have documentation, you meet all of the criteria on the plan and you are denied, they do not have a leg to stand on! Ask your surgeon’s office to arrange a “peer-to-peer” review. This is where your surgeon will speak with the medical director at the insurance company to review your documentation and to point out how you meet the criteria.
<<To view the rest of this article, click here>>
r a potluck and let each guest bring a dish of their own. The guests can bring the traditional meal items.
giving meal. For many people, it is preferable - no leftovers, no fuss, no preparations or cleanup. All you have to do is make reservations.
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