Weight loss surgery insurance appeals can be scary and while you may be going through this for the first time, we aren’t!
Here are some of the most common denials we successfully appeal. While your circumstances are unique and might not match these examples there’s still a pretty good chance we’ve handled a case very similar to yours and can use that experience to help you get approved.
Lack of supervised weight loss efforts
Too many times a payer will insist that a patient go through a “supervised weight loss program” before they will approve surgery. While there are times (such as a 2 week period immediately before your operation) that weight loss has positive benefits and should be encouraged, more frequently these kinds of denials are hoops patients are forced to jump through which have no benefit. We can help you deal with these kinds of denials since we’ve handled hundreds of them with dozens of insurers.Learn More »
Has your insurance plan said your request was denied because this type of surgery “is not a covered benefit” or is “excluded”? This is not always the end of the discussion. There are many times, and many situations, where we can help your surgeon’s office make a stronger request and appeal any denials which may result.Learn More »
Not Medically Necessary
Insurers use their own “medical criteria” to determine whether or not your surgery is “medically necessary” and therefore covered. Maybe they deny you because your BMI is “too low” or maybe they say your co-morbid diseases “are under control.” Sometimes they will claim surgery isn’t medically necessary because you haven’t documented your history of morbid obesity for 2,3 or even 5 years. All of these denials can be challenged.Learn More »
Treatment is Experimental, Investigational or Unproven
Bariatric surgery has been at the forefront of new types of surgical interventions, new medical devices and new ways to operate. When our practice started, we fought denials of laparoscopic surgery because insurers considered it experimental. Now it is standard of care. So whether it is a procedure like sleeve gastrectomy, a device like an adjustable gastric band, or some other cutting-edge intervention, we are the most experienced team helping patients and providers overcome these challenges.Learn More »
You Don’t Qualify For A Revision or Conversion of Your Prior Surgery
The decision to have weight loss surgery is hard for any patient. We know first-hand how difficult it is to consider having a second operation because the first one “failed.” Payers deny these cases routinely, often claiming the patient wasn’t “compliant” with the original surgery’s protocols when that isn’t usually true. You can fight for the revision or conversion surgery you need to get back on track.Learn More »
Massive weight loss after bariatric surgery doesn’t always leave a patient without health issues. Loose skin can cause multiple health problems and it can be medically necessary to reconstruct certain areas of the body. Denials for panniculectomy, abdominoplasty, brachioplasty, breast lifts or reductions and other body contouring may not be just “cosmetic” – they may be vital to your health and worth appealing aggressively. We can help.Learn More »