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Health insurance coverage for bariatric surgery is becoming more common, and the number of different types of surgeries that are covered is increasing. Traditionally, gastric bypass and BPD-DS were most likely to be covered; now, the lap-band and sometimes the gastric sleeve are also covered by many companies.
Determine Whether You're Entitled to Reimbursement
Check the Summary of Benefits (SOB), Certificate of Coverage or Summary Plan Description (SPD) to see if your surgery is covered. Look through the different sections to see if your surgery is mentioned.
- Exclusion clauses: These sections list services that are not covered by the policy. If your policy does not cover bariatric surgery, bariatric surgery might be listed in an exclusion clause.
- Inclusion clauses: These sections list services that are covered by the policy. Your policy might state that all or specific types of bariatric surgeries are covered.
- Expenses Covered or Expenses Not Covered: These might come in the middle of an exclusion clause or an inclusion clause, or they might come in their own separate lists elsewhere in the policy.
Often, insurance policies exclude all bariatric surgeries if they're your second one. A frequent exception is if it's "medically necessary." This can be when:
- You didn't lose at least 50 percent of your excess body weight within the first two years of your first bariatric surgery even though you followed your prescribed diet and exercise program.
- You were losing weight successfully until your gastric pouch dilated, or expanded, and you need a second procedure to make the pouch smaller.
Get Your Pre-Approval in Writing
You need to obtain your pre-approval for reimbursement. Do not accept a "yes" over the phone from your insurance company. Get the promise of pre-approval in writing. You or your surgeon's office may need to send a letter to the company asking for pre-approval.
- Explain the surgery you want and why it is medically necessary
- Identify the surgeon and facility
- Include the Current Procedural Terminology, or CPT, code to identify the specific weight loss surgery that you want
- Use the International Classification of Diseases (ICD), 9th Edition, terminology to describe your medical condition. Your surgeon can help you with the ICD and CPT.
Appeal a Denied Claim if Necessary
It's not unusual to have your first claim denied. Appeal the denial. First, call your insurance representative and request an explanation in writing so that you can address each point. You are legally entitled to an explanation in writing. If needed, write a letter to appeal the denial.
- Double check to make sure you got the CPT and ICD-9 correct
- Point out any mistake(s) on the insurance company's part
- If necessary, explain that the procedure you want is not experimental; it has evidence to support its safety and effectiveness. Your surgeon should help you with this.
- Keep the letter short
The Obesity Action Coalition (OAC) has more guidance on getting the reimbursement that you're entitled to.1
Obesity Action Coalition. Working with your insurance provider: a guide to seeking weight loss surgery. Web site.
http://www.obesityaction.org/educational-resources/brochures-and-guides/oac-insurance-guide/reviewing-your-insurance-policy-or-employer-sponsored-medical-benefits-plan. 2009. Accessed September 27, 2012.