Insurance
Coverage
for
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.
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QUALIFY
Additional Information regarding
insurance coverage for gastric bypass surgery
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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. |
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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.
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Lack of documented
history is the number one
reason for surgery denial.
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.
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