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The discussion of this topic is unavoidable and is in fact essential when discussing treatment for morbid obesity. Unfortunately, the criteria used by many insurance companies as to whether or not a certain benefit will be covered under their policies is not always based upon medical necessity. Because a treatment is medically necessary does not mean that it will be a covered benefit by your particular insurance company or plan. Many insurance companies have their own specific benefit guidelines, describing whether treatment for morbid obesity will or will not be covered. If it is a covered benefit, they have specific requirements that must be met before they will authorize benefits for the treatment. The process can be long and difficult requiring much effort on the part of the patient and the doctor௦fice, but that is the current reality.

The following are what insurances are requiring in order to determine if treatment for morbid obesity is a covered benefit.

  1. Benefit covered? First, information must be obtained from the insurance company as to whether surgical treatment for morbid obesity is a covered benefit under your specific policy. This can be done by reviewing your benefits book and looking for a specific exclusion of this benefit. If there is no specific exclusion, a representative of the insurance company is generally contacted to verify whether the benefit is actually available. Some insurances will be up front and say yes or no, but others will not even say if it is a covered benefit until all documentation is in and a determination has been made about medical necessity. One important point to keep in mind is that obesity and morbid obesity are considered 2 different health conditions. Many plans will exclude treatment for obesity but will cover treatment for morbid obesity. It is important to be very specific in the language you use when dealing with insurance companies. Another important point to keep in mind is that not all representatives of a particular insurance company will be as knowledgeable about their policies as others. Some will not even know what morbid obesity is and you may be misinformed about coverage. It is important to check more than one source to verify that what has been told to you is valid.
  2. Documentation of Dieting. Many insurance companies are asking for documentation of dieting. This can be in the form of diet records from commercial weight loss programs, medical records from your primary care provider or receipts for weight loss programs. Some insurances have gone as far as requiring a 6 month daily record of eating habits.
  3. Documenting Exercise Attempts. Many insurance companies are asking for documentation of exercise attempts. This can be in the form of attendance records at exercise programs, receipts for gym membership and records from rehab appointments.
  4. Psychological evaluation. Many insurances are now requiring some sort of psychological evaluation. This can be in the form of a psychological screen to test your state of mind and ability to cope with surgery. Some insurances are requiring an actual evaluation from a psychologist or psychiatrist.
  5. Medical records. Medical records are required, and must be submitted with all other documentation prior to the insurance company making a determination.
  6. Letter of Medical Necessity. This is a letter usually written by your surgeon that outlines your medical, diet and exercise history and your current state of health. It is the summary of all your information that makes the case for why surgical treatment for your morbid obesity is medically necessary. This letter is usually submitted with all your other documentation.
  7. Predetermination. Once all your records are gathered and sent into the insurance company with the letter of medical necessity, the insurance company goes through a review process to determine if they will approve this benefit for you. At this point they may either ask for more documentation, approve this benefit for you or deny this benefit to you. If you are denied, most insurances have up to 3 appeals that they allow you to make. It is important not to waste these appeals and make sure all documentation is complete prior to filing an appeal. It is also important not to give up during the appeals process as many initial denial decisions are overturned in later appeals.
  8. Precertification. If your benefits for treatment have been approved, a final process of precertification through the insurance company is made, in which the scheduling of your operation, the surgeon you will be working with and the facility at which you will undergo the procedure are determined. Precertification generally must take place within 90 days of predetermination to be valid.

From what has been outlined, you can see how difficult the process can be. I know of no other group of patients that is asked to do so much in order to obtain medical treatment for their health condition, but this is the reality. It is important to not lose hope during the process even though you may run into some stumbling blocks along the way. I do not know why this group of patients is singled out in this manner and asked to do so much but I do know that the result is that some patients will give up somewhere along the process. It is important not to give up, and to keep in mind the long term goal of improving your health and preventing the adverse affects of morbid obesity.

The above is a general overview of what you can expect if you choose to seek surgical treatment for your morbid obesity. Every bariatric surgery program will be different in terms of what level of assistance will be provided to the patient in order to get through predetermination and precertification. If you choose to register with us for surgery, a process is in place that will help you through every step of the process to make it as pain free as possible.

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