Obtaining Insurance Approval for Bariatric Surgery
The process of gaining insurance approval for bariatric surgery can take anywhere from one month up to eight months. Each insurance company has its own medical necessity criteria a patient must meet in order to be approved to have surgery. If the insurance is a commercial insurance, meaning the patient has the policy through their employer, the employer can also dictate the terms of the medical necessity criteria. The employer also has the option to remove bariatric surgery from the insurance policy altogether. This is called an exclusion.
To begin the process of having bariatric surgery a patient would need to contact their insurance carrier by calling the customer service number on the insurance card and asking if they have coverage for weight loss surgery. This is also a good time to inquire about the medical necessity criteria to find out what steps your insurance requires you to take in order to prove that the surgery is medically necessary. All insurance companies require:
• a consultation with the surgeon performing the surgery
• a clearance letter from the patient’s primary care physician
• a psychiatric evaluation.
Most insurance companies require a medically supervised diet. The dieting criteria vary from 3 consecutive months all the way up to 7 consecutive months, depending on the insurance company. Some insurance companies stipulate that the diet must be done with the patient’s primary care physician and some require that the patient lose 10% of their body weight. Insurance companies can also vary on the procedures that are covered. Some insurance companies will not pay for certain types of surgery at all while other insurance companies base coverage on the patient’s body mass index.
After the criteria are met, documentation will be faxed in to the insurance company where it will be reviewed according to the specifics of the patient’s insurance policy. This process can take up to 30 days. Once the insurance company approves the requested procedure as medically necessary and sends the approval letter, the surgeon’s coordinator will contact the patient to start the scheduling process. If the procedure request is denied there are several avenues to take in attempting to have the denial overturned and will be outlined in the letter from the insurance company explaining the reasoning for the denial.
While the insurance journey can be complicated, our practice has employees dedicated to assisting you with each stage of the process. For more information about starting your journey, call 865-694-9676.
Jennifer Johnson, Pre-determination Coordinator