You scratch your head and ask “Why Is This Being Denied?”
After all, you have done your homework, discussed your situation with your surgeon and probably other bariatric team members, and you have all decided to have weight loss surgery. The pre-authorization request is submitted and your insurance company comes back denying care, claiming that the type of surgery you need falls under their definition of experimental, investigational or unproven therapy. The plan language might read something like:
…medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time we make a determination regarding coverage in a particular case, are determined to be any of the following: Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use Subject to review and approval by any institutional review board for the proposed use (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be Experimental or Investigational) The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight There is insufficient data to draw long-term conclusions that this therapy is superior to established alternatives…
Our office has a longstanding history of supporting evidence-based new technology and therapeutic interventions and we are the best resource available to help you get this denial overturned. We have been fighting these cases since the late 1990’s, at a time when laparoscopic bariatric surgery was in its infancy and cases were being routinely denied. Today, laparoscopic access for all forms of bariatric surgery are not only not experimental, they are the STANDARD OF CARE!