Insurance Approval 101
The insurance approval process prior to bariatric surgery can be very confusing and frustrating, but with a little patience and determination you will reach your goal and be ready for surgery. The Pre-Determination Coordinator is a full-time employee dedicated to helping you decipher your insurance’s requirements, meet the criteria set forth, and get you approved for your surgery. A helpful tip may be to outline the criteria specific to you, and create a checklist for yourself. It is very helpful to be able to see what needs to be done and very affirming to see all that you have accomplished. All insurance companies require patients to be morbidly obese. A person with a Body Mass Index (BMI) of 35-39.9 with a comorbid condition such as Hypertension, Diabetes II, Obstructive Sleep Apnea requiring the use of a device such as a CPAP, or Degenerative Joint Disease meets the criteria. Patients with a BMI that is greater than 40 are not typically required to have a diagnosed comorbid condition. Medicare is the exception to this rule. All patients with Medicare or a Medicare replacement policy must have a diagnosed comorbid condition regardless of BMI.
There are 2 main categories to address prior to having surgery:
1: Requirements everyone must meet
2: Requirements specific to your insurance policy.
The first category, requirements that everyone must meet, applies to patients whether they are paying for surgery on their own or going through their insurance company. After attending a seminar and having a consultation with one of the surgeons, everyone must undergo psychiatric evaluation by a doctorate level psychiatrist or psychologist and receive a mental health clearance. The psychiatric evaluation usually consists of a combination of personality testing and an interview. Patients must also be given a medical clearance by their primary care physician. A letter stating that you are cleared for bariatric surgery is sufficient. Your surgeon may want you to have other specific clearances from any specialized physicians that you see. This will be discussed with you at your consultation. We also ask all patients to attend at least one (1) bariatric support group meeting. There are several different groups to choose from located in the area surrounding Knoxville to increase convenience and accessibility to everyone. Each support group meets once monthly. We will supply you with a list of the support groups, when and where they meet, and directions. This list can also be found on our website.
The second category, requirements that are specific to an insurance company, can vary greatly. The most common requirements of an insurance company are medically supervised dieting, documentation of weight history, and evaluations by a dietitian and/or exercise physiologist. A medically supervised diet is usually 6 consecutive months in duration with at least one (1) office visit monthly. However, some insurance companies only require a three (3) month medically supervised diet, and a few do not require a diet at all. Usually your initial consultation with the surgeon is considered the first month of your medically supervised diet, but a few insurance companies require that all 6 visits be with a primary care physician. During your medically supervised diet you may be required to meet with a dietitian and an exercise physiologist. These appointments will also be considered a medically supervised diet visit so you will not have to be seen 2 times in one month.
For example, an insurance that requires a 3 month diet with a dietitian and exercise physiologist evaluation could be done as follows:
Month 1 – Consultation with surgeon. Month 2 – Meet with exercise physiologist. Month 3 – Meet with dietitian. At this point your medically supervised diet would be complete.
Medically supervised diet visits can usually be done with your primary care physician or with Covenant Weight Management Center. Remember though, some insurance companies do require that the diet be done with a primary care physician.
Your insurance company may also ask to see documentation that you have been morbidly obese for an extended period of time, usually five (5) years. One office note per year for each of the previous 5 years with a documented weight will satisfy this requirement. If you doctor uses a form to record the date and your weight at each office visit, sometimes called a ‘vitals sheet,’ we can use that as well.
Once you have completed these requirements it is time to request approval for your surgery. The Pre-D Coordinator will assemble a packet and pre-approval surgery request letter. This packet will be sent to your insurance company for review by a nurse coordinator and medical director. The average amount of time to hear back from an insurance company is 2 weeks. Some take longer and some respond sooner. When we receive the approval letter from your insurance you will be contacted by our office. If, for any reason, we receive a denial, the Pre-D Coordinator will research as to why the request was denied and begin working with you and your insurance to rectify the situation and gain approval. There are some instances in which a denial cannot be overturned. An insurance policy that excludes bariatric surgery will not overturn a denial since the service is not a covered benefit. Denials due to the patient not meeting the specific requirements set forth by the insurance company are handled on an individual case-by-case basis.