Getting Insurance Approval For Gastric Bypass Surgery

One of the first hurdles you’ll have to jump in preparing for gastric bypass surgery is getting the approval of your insurance company.

Fortunately, more and more companies are extending coverage for weight loss surgery. They’ve seen the research that shows insurance companies generally recoup the cost of gastric bypass surgery within 2-4 years, thanks to the range of benefits beyond weight loss.

But that doesn’t mean that approval will be automatic – or that your individual policy covers weight loss surgery. Some small businesses exclude WLS from their group benefits in order to keep costs down.

Make Sure Your Policy Covers Weight Loss Surgery

So the first place you want to go is to your own policy. Call customer service and ask them about your coverage – and be sure you write down the name of the person you speak to. That way if someone else gives you different answers later, you can say, “Ann Smith said my policy requires X and Y for coverage.” Instead of “well, I spoke to a lady 3 weeks ago, and she said…” Ann Smith can be verified. “Some lady” can’t.

Once you know your policy will cover gastric bypass surgery, you can make a list of the requirements you’ll have to meet and begin working toward them.

Common Insurance Requirements
For Gastric Bypass Surgery

I, personally, have insurance with Blue Cross/ Blue Shield of North Carolina. I was required to submit the following for approval:

  • A letter of medical necessity from my primary care physician, also stating that my BMI was over 40, or that my BMI was over 35 and I had significant co-morbidities
  • Medical records showing my height and weight at check-in, for appointments occurring in 5 different years (not including the current year), also showing that my BMI was over 40
  • A psychological evaluation finding that I understood what I was getting into and that I was mentally healthy enough to undergo the drastic changes ahead
  • Proof that I had attended a nutritional evaluation with a dietician

I submitted all of the above and was approved right away. Other companies and plans, however, require a few more things, such as:

  • Documentation of a 6 month or longer medically supervised diet. There is some dispute as to whether you’re expected to have succeeded or failed to lose weight on this diet, or even whether it matters. If your insurance company requires this, it wouldn’t hurt to ask what kind of result they’re looking for.
  • Documentation that all correctible causes of obesity have been ruled out with test results (such as a thyroid panel, etc)
  • A detailed description of the limitations your obesity places on your daily activities
  • A detailed history of the results of your dieting efforts, including medically- and non-medically-supervised programs
  • A history of exercise programs, including receipts for memberships in health clubs

It also never hurts to have a full list of every possible negative side-effect of obesity you suffer from, such as

  • High blood pressure
  • Diabetes
  • Cardiovascular disease
  • Sleep apnea
  • Gastroesophageal reflux
  • Infertility
  • Arthritis
  • Dyslipidemia (a disease characterized by a high concentration of lipids and cholesterol in the blood; a risk factor for heart disease and cardiovascular disease)
  • Urinary stress incontinence
  • Any other obesity-related conditions

Most gastric bypass surgeons have someone whose primary job is getting insurance approval for potential patients. (Read: who’s job is to make sure potential customers can pay for the service.) It’s in their best interests to help you in every way they can. And since getting approval for surgery is their full-time job, most are pretty good at getting it done.

What Happens If Insurance Coverage
For Your Gastric Bypass
Is Denied?

You wait on pins and needles to hear back from the insurance company, only to find out the answer is “no.” Very few things can be so disappointing. But it’s not necessarily the end of the line for your hopes of having weight loss surgery.

Some insurance companies make it a policy to automatically deny nearly all requests the first time they’re submitted. (I, for example, used to have CIGNA. When I needed a hysterectomy, my GYN submitted everything and was turned down. She said the letters stand for, “Call In, Get ‘No’ for an Answer.” She re-submitted and I was approved.)

So, if you’re turned down for gastric bypass surgery, is that the end of the story? Only if you let it be. A strong appeal letter can often make all the difference.

Hopefully, you’ll be given a reason for the denial. And it could well be that your problem is simply a matter of missing paperwork. In that case, gathering the missing data and resubmitting your request can be all you need.

Other times, your insurance company may quibble with the “medical necessity” of your gastric bypass surgery. In this case, you’ll have to craft a strong appeal letter stating the medical problems caused by your obesity as well as any research you can find showing that weight loss surgery can benefit them.

Again, your surgeon’s office should be able to help you appeal the denial of coverage for gastric bypass.

More Resources For Getting Your Weight Loss Surgery Covered By Insurance

Craig “Big-T” Thompson was one of the first patients to undergo gastric bypass surgery back in 1997. Yet when he first submitted his paperwork to his insurance company, he, too was denied.

He spent months researching insurance companies and how they work. And he discovered the secrets of how to communicate with them. Best of all, he discovered how to get your gastric bypass surgery covered, even if you’ve already been denied.

You can learn about Craig’s incredible story, and find out how you, too, can learn his secrets when you visit his website: Weight Loss Surgery Insurance Secrets.

Once you’ve made the decision that gastric bypass surgery is right for you, don’t let some faceless bureaucrat deny you – especially if you know that your insurance policy is supposed to cover weight loss surgery. Even if your company says it doesn’t, Craig says there are ways to get your surgery covered. And he’s helped others do just that. So go ahead and visit him at Weight Loss Surgery Insurance Secrets today.


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