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​Paying for Surgery

How to Get Approval for Your Surgery

A growing number of states have passed legislation that requires insurance companies to provide weight loss surgery benefits for patients who meet certain criteria. While insurance coverage for weight loss surgery is widespread, there is often a lengthy, complicated approval process. Here are some of the key steps you should take to obtain approval from your insurance company for weight loss surgery:

Read and understand your certificate of coverage. Your insurance company is required by law to provide you with this document. If you do not have a certificate of coverage, consult your employer's benefits administrator or ask your insurance company directly.

Start with your primary care physician. In most cases, your primary care physician must refer you to a qualified bariatric surgeon. Even if you are not required to get a referral, it is a good idea to have the support of your primary care physician.

Organize your medical records. Before visiting your bariatric surgeon, it's important to gather information about your health, including your history of dieting efforts. These valuable documents will be used at every stage of the approval process.

Document every visit. When you consult with a health care professional or participate in a supervised weight loss program for obesity-related issues, it's important to track this information. Document weight-loss attempts through joining diet centers and fitness clubs. Keep good records, including receipts.

Get a letter. To obtain pre-authorization for surgery, your surgeon will need to write a letter to your insurance company. The goal of this letter is to establish the medical necessity of weight-loss surgery and gain approval for the procedure. The following information is usually included in the pre-authorization letter:

  • Height, weight and body mass index
  • Documentation supporting how long you have been overweight
  • Full description of all obesity-related health conditions and how they have affected your life, including records of treatment and history of medications taken
  • Detailed description of the limitations your excess weight places on daily activities, such as walking, tying shoes or maintaining personal hygiene
  • Detailed history of your dieting efforts, including medically and non-medically supervised programs
  • Detailed history of exercise programs, including receipts for health club memberships
  • Information from medical journals regarding the effectiveness of weight loss surgery, particularly information showing the control or elimination of obesity-related health conditions.

It's standard for insurance providers to respond to your request within 30 days. You should follow up if you have not received a response in that time.

The Appeals Process

If your initial request for pre-authorization is not approved, you still have options. Insurers provide an appeals process that allows you to address each reason they have denied your request. It is important that you reply quickly. You may also want to enlist the help of an experienced insurance attorney or insurance advocate to properly navigate the complexities of the appeals process. Some insurers place limits on the number of appeals you may make, so it is important to be well prepared.