Insurance Process for Weight Loss and Bariatric Surgery

by Robin Shortell
Insurance Coordinator, New Jersey Bariatric Center

Due to the growing popularity of weight loss surgery – gastric bypass and lap band surgeries - insurance companies across the United States are making the approval process more difficult, therefore causing appeals to become more and more common. Insurance providers are no longer looking for reasons to approve these surgeries; instead they’re looking for any and every reason to deny them. They view weight loss procedures as cosmetic, rather than as a medical necessity and the serious procedures that they are. Establishing medical necessity becomes the key to getting an insurance company to authorize a surgery, but it’s a long, detail-intensive process that requires diligence, patience and partnership from both the patient and the insurance coordinator to make it happen. Though each insurance policy is different, and should be verified individually for more specific details, the majority of them require similar information to help determine medical necessity and avoid the appeal process.

The presence of morbid obesity, a BMI (Body Mass Index) of 40 or higher, or a BMI of 35-39 in conjunction with significant co-morbid conditions – heart disease, high blood pressure, diabetes and sleep apnea - for at least five years is the primary determinant for insurance companies. Most commonly office notes containing records of your weight from previous visits to primary care physicians, specialists for obesity related conditions, and nutritionists are used to fill this requirement. This information is essential in the process; it is what the insurance companies use to ensure that weight loss surgery is reserved only for those who have been unsuccessful in significant weight loss efforts. An authorization is unlikely without this documentation, so to facilitate submission of your case it is beneficial to contact your doctors for all of your medical records and have them forwarded to the office.

Participation in a medically supervised weight loss management program is a crucial detail in the approval process and is required by most insurance companies. For example, Horizon BCBS of New Jersey recently updated their Bariatric Medical Coverage Policy Number 22 in June 2007 to limit access to bariatric surgery by adding the need for 6 month medically supervised program and five year weight loss history. These programs generally entail monthly appointments with the office to document weight and manage the progress of each patient, nutritional counseling for adequate eating habits, psychological counseling for behavioral modification, as well as participation in an exercise regimen. The duration of the program will vary with each insurance company, but is usually between three to six months. Although a six month weight loss management program might prepare a patient to better understand weight loss surgery, there is ample medical literature that demonstrates preoperative medically supervised weight loss program is an ineffective treatment for morbid obesity and in fact has no measurable beneficial effect prior to bariatric surgery. (1, 2) Note that this is not required for Medicare patients and these guidelines are not consistent with the National Institute of Health. (3)

Documentation is needed every step of the way. Insurance companies will ask for documentation from each office visit, so it is important that you keep all scheduled appoints and visit the office at least once a month for as long as your insurance company requires. A missed appointment can ultimately result in a denial from the insurance company. In addition, supporting letters from a nutritionist, psychologist, and exercise professional are required, so those appointments are just as important to keep.

An authorization may take as long as four weeks or as little as one week depending on the content of the submitted information. All of the above documentation is required, but information overload is the key. Providing your insurance coordinator with information such as documentation of any previously tried weight loss medications, previous nutritional counseling, or any other attempts at weight loss will help the approval process along. YOU CAN NEVER SEND IN TOO MUCH INFORMATION. The more information the insurance company has to review the higher the chance of a fast approval. We recommend you keep a detailed log of your appointments. During the course of your weight loss management program you will be extremely busy keeping up with all of your appointments and insurance companies are counting on you missing something, and a log of your hard work to date will help you stay one step ahead. Remember that all of the above requirements need to be completed before we submit a request for authorization as insurance companies look for these specific documents before even reviewing the information, and should any of these items be missing it will result in an immediate denial.

In the event of a denial, we will work with you to help overturn this decision. As a patient, and a paying customer of your insurance company, your voice will have the most significant impact in the appeals process. Let your voice and dissatisfaction be heard loud and clear regarding the limitations brought on by your insurance companies. First, speak to your insurance company directly and appeal your case to the medical director, both verbally and in a letter documenting your efforts. Next, contact Ms. Heather Howard, the New Jersey Commissioner of Health to share your thoughts on the limitations imposed by your insurance provider. Finally, contact the New Jersey Department of Banking & Insurance (DOBI); it can also help with unfair practices of insurance companies.

Tackling the insurance process can be emotionally draining, but to keep your spirits up and your perseverance strong remember what you’re fighting for – the opportunity to live healthier life. For more information on the insurance process you can contact the office at (908) 378-1779.

1. Jamal MK, DeMaria EJ, Johnson JM, Carmody BJ, Wolfe LG, Kellum JM, Meador JG. Insurance-mandated preoperative dietary counseling does not improve outcome and increases dropout rates in patients considering gastric bypass surgery for morbid obesity.
Surg Obes Relat Dis. 2006 Mar-Apr;2(2):122-7.

2. Presutti RJ, Gorman RS, Swain JM.
Primary care perspective on bariatric surgery.
Mayo Clin Proc. 2004 Sep;79(9):1158-66; quiz 1166. Review.

3. National Institute of Health. Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Int Med 1991;115:956-961

COMMONLY ASKED QUESTIONS:

How many visits are required with the Nutritionist and Psychologist for clearance?
Generally one visit with each should suffice, unless otherwise recommended by your surgeon.
For the best chance of approval, be sure to visit with a nutritionist and psychologist who have experience with weight loss surgery patients as they’re familiar with the specific details insurance companies look for when reviewing submissions.

How many visits are required for the exercise regimen?
Our office works with Ivy Rehab, an exercise center located near both offices. They offer a program that can be completed in three sessions. Ivy Rehab accepts most insurances, but again benefits should be verified prior to your visit.

What co-morbid conditions are used to determine morbid obesity if my BMI is between 35-39?
Though there are numerous conditions directly related to being overweight, however insurance companies only view some of them as being life-threatening in conjunction with Morbid Obesity. Those conditions include Hypertension, Diabetes, Coronary Artery Disease, and Sleep Apnea with the use of a C-Pap machine. It is important to contact your insurance company for this information as many plans may require more specific details related to these conditions.

Do all insurance companies cover Weight Loss Surgery? Most plans do allow coverage for weight loss surgery, however there are sometimes exclusions on services related to Morbid Obesity. To avoid any misconceptions, contact the office for further details on your policy.

WHAT YOU CAN DO TO HELP THE APPROVAL PROCESS:

Begin gathering a five year weight loss history.
Obtain all records relating to your weight or weight loss efforts.
Meet with Nutritionist and Psychologist as soon as possible
Keep all office appointments. Should you need to cancel contact the office to reschedule your appointment in that same month.
Get involved! Call your insurance company and your insurance to send you the guidelines. Take the name of the person you speak to.

FOR HELP WITH INSURANCE VERIFICATION YOU CAN FAX YOUR INSURANCE CARD TO THE OFFICE AT (908) 688-8861 ATTENTION ROBIN. PLEASE INCLUDE THE FOLLOWING INFORMATION WITH YOUR FAX:

• Front and back copies of your insurance card
• Your date of birth
• Your social security number
• A contact phone number to receive a call back on benefit information