Insurance Coverage and Gastric Bypass Surgery
Gastric
Bypass Surgery is a covered by many insurance companies.
Coverage depends on what type of policy you have and the
terms within the policy. Each insurance policy can vary
greatly, even if different policies are issued by the
same company.
Some patients choose to pay for the Gastric Bypass
procedure on a self- pay basis. This type of arrangement
can be made by calling Obesity Surgery Specialists and
speaking directly with our insurance coordinator. There
are two separate fees that you will need to consider,
one is for the surgeon and the other is for the hospital
at which you stay. Gastric Bypass surgery usually
requires 2-3 days in the hospital and 2-6 weeks for
recovery, depending on your type of work.
Will my
insurance pay for my surgery?
Insurance
coverage for the Gastric Bypass procedure depends on a
determination by your primary care physician, surgeon or
specialist that gastric bypass surgery is medically
necessary to reduce significant medical risks to your
life. Your insurance carrier will also require:
-
A
thorough medical history
-
A
detailed diet history over the past two consecutive
years under medical supervision
-
Current
height, weight and BMI (body mass index)
-
A list
of all co-morbidities that are or may be caused by
your morbid obesity
-
A
psychological evaluation/clearance
-
Must be
included in a letter of medical necessity written by
your primary care physician and provided to the
Obesity Surgery Specialists for submission to your
insurance company.
What if my
insurance denies my claim?
If your insurance denies coverage for
the gastric bypass surgery, don't give up hope. In many
cases, providing additional information in the form of
an appeal letter could result in your denial being
overturned. If your insurance carrier continues to deny
coverage, you may consider seeking legal assistance.
Insurance companies will often relent to avoid
confrontation.
Additional
Information regarding insurance coverage for gastric
bypass surgery
Most
insurance companies follow the recommendations of the
National Institute for Health when they set up their
guidelines to qualify for surgery. However, some
insurance companies have offered an “exclusion” to
employers when contracting for an insurance policy.
This means that your employer may have elected to not
cover the medical treatment for obesity or morbid
obesity.
Some
insurance companies will require documentation of a
history of morbid obesity. You can easily obtain these
records from any physician you have seen in the past.
This includes
your primary care physician, internal medicine
physician, gynecologist, pediatrician, or any other
physician who has kept track of your weight.
Insurance
companies will not accept a summary letter from your
physician…they will need the actual office visit
records.
If you have
taken
any medications that were prescribed by a physician to
assist in weight loss, the insurance company will want
to see these records.
Records from
Weight Watchers, Jenny Craig or other diet programs are
generally not accepted for documentation of attempted
weight loss, but if you can get these records they may
be helpful as supporting documentation.
Some insurance companies will require pre-operative
evaluation and clearance for members who have a history
of severe psychiatric disturbances or who are currently
under the care of a psychologist/psychiatrist or who are
on psychotropic medications.
All HMO insurance
companies will require a referral to the treating
physician. They may also require that you stay within a
certain list of physicians. You should check this out
with your primary care physician early in the process.
Ask questions – if weight loss
surgery is covered by your insurance, ask the company to
send you their policy bulletin or treatment guidelines
regarding coverage. This document will tell you
everything your carrier requires for coverage. Pay
particular attention to any requirements for diet
history. The lack of documented history is the number
one reason requests for this surgery are denied.
We will work with you to get what you
need and can submit the letter of medical necessity to
your insurance company. We will do everything legally
possible to help you get an approval from your insurance
carrier.
