It can be very discouraging if your insurance company denies the pre-authorization request for coverage of lap band surgery. If you receive a denial, however, don't give up! Instead, appeal the decision. Like many other lap band patients who were initially denied coverage, you too may find that it is possible to gain approval through the appeals process.
Denial of Coverage Notification
When you receive a notification of denial, the first step towards filing an appeal is to determine why the insurance company denied your request. Once you know the exact reason why coverage was denied, then you can proceed with gathering the information needed to overturn the initial decision.
When you follow-up with the insurance company for details, be polite yet persistent. Not only do you want to find out why the surgery was denied, but you want to find out what information the insurance company requires for approval. The insurance company may not make it easy for you, but don't let that stop you from working through the appeal process.
Paperwork and Documentation
Many pre-authorization requests for coverage of bariatric surgery are denied simply because of incomplete paperwork and lack of proper documentation. While you may know that you have struggled with obesity for years and have tried to lose weight with diet, exercise and medically supervised plans, the insurance company will not know that unless you provide them with all the "evidence" to this effect, including documentation of doctor visits for weight loss, receipts of diet and exercise programs, and medical history records. Since there is no such thing as providing too much relevant information, be thorough and submit all the proof you have of previous weight loss attempts. The documentation you provide to the insurance company can make a difference as to whether or not you are granted coverage for surgery.
Meeting Patient Criteria and Medical Necessity
Coverage for lap band surgery often depends on whether or not an individual meets The National Institutes of Health (NIH) patient criteria for weight loss surgery and if the procedure is considered a medical necessity. Both of these conditions can be established by your doctor and presented to the insurance company in a Letter of Medical Necessity. The statement your doctor provides to the insurance company about your obesity and weight related health problems is very important in showing your insurance company the medical necessity of weight loss surgery. Your doctor should be more than willing to write a letter to your insurance company as a way of helping you present your case for coverage of lap band surgery, both in the initial request and in the appeals process.
Appealing an Exclusion for Weight Loss Surgery
Even if your insurance plan excludes "obesity surgery" or "treatment of obesity" it may still be possible to appeal and win. Bariatric surgery has been shown to be an effective treatment for many other diseases, including type 2 diabetes, hypertension (high blood pressure), and obstructive sleep apnea. Since these diseases are usually covered by health insurance, the appeal would be based on your doctor's opinion that bariatric surgery is the best method for treating your health problems. Documentation should be presented to the insurance company showing that other treatment methods have not been effective in controlling or curing the disease.
Writing An Insurance Appeal Letter
When you are informed of a denial there is usually a date limit to respond. While it is important to appeal within a timely manner, it is also important to respond effectively. When appealing, write a letter that is factual and persuasive, yet pleasant and polite. Make sure you include all the relevant information and include the supporting documentation to establish patient criteria and medical necessity. Make copies of everything you send for your own records and then send the package with tracking information for proof of mailing.
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