Overview Of Insurance Coverage Requirements For Weight Loss Surgery

By | January 25, 2018

requirements for weight loss surgery

Requirements for weight loss surgery – The specific coverage of insurance companies, health plans and even between states varies. Some states have passed laws requiring insurance companies to cover weight loss surgery If the patient meets the health standards of national health institutes. Some insurance corporations can cowl either half or the whole value of surgery as long because the individual meets bound patient standards and surgery is medically necessary owing to critical conditions caused by fatness.

Even among insurance companies that provide coverage for the cost of weight loss surgery, the benefits of surgery are usually not considered unless other methods of weight loss are attempted. The request for prior permission often requires the patient’s prior involvement in the medical weight loss Program under the supervision of the physician with documented weight loss attempts.

Some insurance companies only require six months history, while some insurance companies want to see the date 1-2 years. Other weight loss attempts may also be requested and the weight loss date before that time.

aetna requirements for weight loss surgery

Intent of weight loss surgery requirements

The National Institutes of Health (intention), a branch of the United States Department of Health and Human Services, is one of the most important medical research centers in the world. National Health institutes have developed patient standards for surgery for weight loss that stipulate that qualified patients must have a BMI of 40 or higher (obesity) or BMI is at least 35 with common morbidities (health conditions related to obesity) such as diabetes, disease and a To heart, high cholesterol, high blood pressure (hypertension).

Qualified patients should even have tried and unsuccessful in previous weight loss efforts and want to pass a psych analysis that’s suggested for weight loss surgery.

Medical Necessity Message

Most insurance companies require a letter of medical necessity for obesity surgery before authorization. The medical necessity message is a phrase written by the patient-doctor detailing the patient’s health condition and the cause of weight loss surgery is necessary. It often lists the patient’s weight and body mass index (MI), and how many years the patient was overweight/obese, and previous attempts to lose weight, participate in the weight loss program under medical supervision, and obesity-related health problems.

Weight Loss program under medical supervision

Many insurance companies will not consider applying for weight loss surgery unless the patient has previously participated in the weight loss program under medical supervision. This type of weight loss program includes diet, exercise, or weight loss medication that is monitored by the doctor. The purpose of this demand is to point out the patient’s efforts in weight loss, which the patient is willing to create the required dietary and behavioural changes for surgery to treat fatness.

Useful documentation for approving insurance

In addition to the medical necessity letter written by your doctor, there are several documents that must be included with your insurance request to improve the likelihood of obtaining surgery approval. Useful documents include all records of the diet, medical records, medical tests and records of the food system’s attempts for medical supervision and receipts for sports equipment and membership in the gym or diet programs such as Wet Wachz or Jenny Craig and any other documents Your attempts to lose weight have been shown over the years.

Appellate Appeal insurance for obesity surgery

If you send a request for prior permission from weight loss surgery and get a denial from your insurer, it may be frustrating but can be challenged. Many refusals are based on factors that can be developed, such as loss of medical history and documentation of weight loss. If you receive a denial, contact your insurance company to see the reasons for the denial and what information you need to grant insurance coverage for the treatment of obesity.


Many individuals followed up with their insurance company to determine the reasons for the refusal, then met those requirements, filed an appeal with the requested information and succeeded in denying their denial. The insurance company may not make an easy process for you, but if you are still working on your behalf you may eventually get an insurance approval for surgery to treat obesity.

While dealing with an insurance company can be overwhelming, you should not have to deal with your own insurance requests. Your obesity surgeon must be both experienced in dealing with insurance companies and ready to work on your behalf. If you and your doctor are unable to convince the insurance company to pay for the weight loss surgery, you may want to consult with the Linstrom obesity call (www.wlsappeals.com), formerly known as the Center for obesity and self-defense, for help and advice.

Appellate Appeal Insurance quoting the lack of medical necessity

Insurance requests for obesity are often denied because the insurance company indicates that there is no medical necessity. In order for the insurance company to be considered medically necessary, it needs evidence to support this claim–such as documents showing that other methods of weight loss have been already tested, and why obesity surgery is essential for treating a serious or life-threatening disease (obesity or type II diabetes). Obesity treatments are considered a last resort and will not be covered unless other methods of weight loss are exhausted.

Lack of proper documentation, such as medical records for one to five years of supervision of a physician dieting, the same assessment me, or a letter from your therapist’s common obesity morbidity, can lead to denial of medical necessity. Ensure that the insurance company is provided with the information required to support the claim that the obesity surgery is medically necessary.

Resume insurance plan exceptions to weight loss surgery

In addition to treating obesity, obesity surgery is now an effective remedy for many diseases and metabolic conditions including diabetes from type 2, high blood pressure, high blood cholesterol, apnea during sleep, non-alcoholic fatty liver disease. Even if your insurance program has AN exclusion for “obesity surgery” or “treatment of obesity” it should cowl treatments for the on top of health conditions. If you have any of these common ailments in obesity, the appeal will be based on the recommendation that obesity surgery is the best way to treat these listed diseases, which usually cover health conditions.

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