How to Appeal a Weight Loss Surgery Exclusion

Weight loss surgery is a lifesaving procedure that allows many overweight people to live a healthy life. Gastric band surgeries, such as the Lap-Band, in which a band is placed around the opening of the stomach and inflated to give the patient a feeling of fullness, is one of the most common types of weight loss surgery. Gastric bypass surgery is a procedure in which the stomach is made smaller and a large portion of the intestines are bypassed by connecting a portion of the intestines directly to the stomach. Stomach stapling is another option in which the size of the stomach is surgically reduced. Many insurance companies limit patients' access to these surgeries with exclusions. However, it is the patient's right to appeal this exclusion.

Instructions

How to Appeal a Weight Loss Surgery Exclusion

• 1

  Verify that weight loss surgery is, in fact, excluded from the policy. Sometimes insurance companies will not list weight loss surgery on the list of covered procedures in an effort to reduce the number of claims that they have to pay. Other times, the insurance company will attempt to deny the claim by saying that the morbid obesity is a pre-existing condition. Call the insurance company to see if this is the case.

• 2

  Ask your doctor to write a letter of medical necessity. This will be required in the appeal to the insurance company. Be certain that your doctor includes your weight, how many years you have been overweight and any medical conditions that you suffer from as a result of your obesity in the letter. A patient must be morbidly obese, which is defined as having a BMI (Body Mass Index) of greater than 40. A patient's BMI is determined by a ratio of a patient's height to the patient's weight. A patient or doctor can determine BMI by using a calculator (see Resources).

• 3

  Create a list of all of the weight loss programs that you have tried and failed with in the past. Gather all available information from commercial weight loss programs that you have tried, such as Jenny Craig and Weight Watchers, and medically supervised weight loss programs, such as Medi-Fast.

• 4

  Mail the letter of medical necessity, your list of attempts at weight loss and all of your documentation to the insurance company. Ensure that the packet is mailed with delivery confirmation to verify that the insurance company receives it.

• 5

  Reply promptly to all correspondence from the insurance company. Continue to appeal all denials. Most insurance companies will deny a claim expecting that you will switch insurance carriers within the next two years. Persistence often pays off.