What to Do When Your Insurer Denies Your Weight-Loss Surgery
If you have ever had been on the telephone with an insurance representative for a ridiculous length of time, then you know how difficult the process can be: periods of silence while information is fished from a resistant computer program, an abyss of repetitive questions, explanations that only a Harvard grad can understand.
When you finally return the phone to the cradle after what seems like eons, you do so without satisfaction. There has been no resolution. Your claim for gastric bypass is denied.
Causes for Denial by an Insurance Company
Insurance companies say no. It is part of who they are. Decisions are based on profit motive, and denials are common place. Your request for gastric bypass can be denied if you provide information that is not accurate or if gastric bypass surgery is not covered under your plan.
In addition, your request for gastric bypass surgery can be denied if you have a pre-existing condition, if weight loss surgery is not medically necessary, or if the weight loss surgery is experimental.
If you are denied, you have the right to appeal the decision.
The Appeals Process
The appeals process can be both time consuming and challenging, so be prepared.
You will first need to get the reason for your denial in writing from the insurance company. It should include specific information such as the criteria used for the review and the name and credentials of the person who issued the denial for your weight loss surgery.
Your insurance company will have guidelines for an appeal. Contact them for the information and follow the protocol.
Seek help from you bariatric surgeon's office. They should be able to expedite the process.
Compose a detailed letter of appeal to your insurance company and begin keeping a record of all the correspondence you have with them.
Continue pursuing until you get a final answer in writing from the insurance company regarding your weight loss surgery.
How to Write a Letter of Appeal to a Health Insurance Company
You can begin by contacting your bariatric surgeon's office to see if they have a sample appeal letter that you can use as a guide. Some bariatric surgery practices actively help with the appeals process and some do not. If your surgeon's office does not, then find a bariatric surgeon who will fight the appeals process with you!
When you compose your letter of appeal for your bypass surgery you must include your full name, your policy number, the treatment description, the treatments dates, and the total charges you have incurred.
You should document the reason you were given for the denial of your weight loss surgery and your intention to appeal the denial.
You will need to document the records that the insurance company used to support their denial of your bariatric surgery, the records you will need to get approval for your weight loss surgery, and copies of the medical opinions supporting the denial.