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How to Appeal When Insurance Denies Bariatric Surgery

OC Staff Insurance and Costs, Pre-approval Process

Its very possible that your insurance company denied your first request for coverage of bariatric surgery. This is often true even if your insurance company specifically has a policy to cover weight loss surgery for qualifying patients. In fact, some surgeons suggest that as many as 40% of patients have to appeal their insurance company’s initial denial before the company consents to cover the surgery.

Did you Know?

You may only have one chance to appeal your insurance company’s decision to deny surgery! And you may have to appeal by a specific date. Read the fine print on the letter of denial!

Why Were You Denied Coverage?

Before doing anything it is utterly important that you fully understand why you were denied weight loss surgery. There are many possibilities that range from straight-forward to inane. These can include denial for not meeting a clearly specified criteria such as level of obesity, not passing psychological exams (diagnosed with bipolar disorder or untreated depression can result in denial), to not going to an approved nutritionist. A solid understanding of why you were denied coverage will allow you to provide the proper documentation for your dispute.

Key Points When Writing a Letter of Appeal

If your insurance company denied your initial request for bariatric surgery coverage than you or your surgeon must write and submit a proper letter of appeal to the insurance company. Its important to do the following before writing your letter of appeal.

  • Call your company’s Human Resource Department and explain the situation.
  • They may be able to provide:
    • The policy that shows or doesn’t show coverage.
    • They may be able to tell you that it should be covered.
    • They may even call the insurance carrier on your behalf.
    • A thorough understanding of why your insurance company denied your pre-authorization for bariatric surgery?
  • Read your insurance company’s policy of coverage for weight loss surgery.
  • Do you meet every criteria listed in the policy?
  • Do you have proper documentation for all of the criteria?
  • Do you have all documentation of your previous interactions with your insurance company about bariatric surgery?
  • Ask your surgeon about their experience appealing denials with your insurance company.
    • If they have little or no experience, consider doing it yourself or…
    • Consider hiring an attorney that specializes in appeals for bariatric surgery.

See a sample letter of appeal to re-apply for bariatric surgery


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