Anyone who looks into bariatric surgery for themselves or a loved one learns very quickly that the process is neither simple nor quick. To start with, there are complex medical questions to consider and decisions to make, such as:
- Is bariatric surgery right for me?
- Which type of weight loss surgery (sleeve gastrectomy, RNY gastric bypass, SADI-S) will give me the outcome I want?
- How much weight will I lose? Will I need reconstructive surgery because of excess skin?
- Will weight loss surgery cause my co-morbidities (type 2 diabetes, GERD, sleep apnea, hypertension, etc.) to improve, or even resolve completely?
Your metabolic/bariatric surgeon and their multidisciplinary team can address these medical questions, but what about the questions you have about insurance and weight loss surgery? Not only are insurance questions a key part of a patient’s decision-making process, the answers can determine whether access to potentially life-saving surgery is possible.
If you are considering bariatric surgery, you may have insurance-related questions such as:
- Will my insurance cover bariatric surgery?
- How can I prove my weight loss surgery is medically necessary?
- What does it mean if my insurance says weight loss surgery is excluded from my plan?
But a patient’s worst insurance question sounds something like: “My insurance company denied coverage for my weight loss surgery. Who can I turn to for help?”
Two Bariatric Surgery Denials Leads to a Dead End … and a Phone Call
Let’s look at a real-life example. Donna wanted bariatric surgery, but she was denied by her insurance. Her physician did a “peer-to-peer” conference with a medical director, but the insurance company stood by its decision.
The surgeon’s office sent an insurance appeal using the same documentation they sent the first time. The denial was upheld again, and Donna was told all her appeal rights were exhausted and there was “nothing that could be done.” Her final act of desperation was to call PRIA Appeals to get a free assessment of her situation. Donna recounted her story to Kelley Lindstrom, who has more than 20 years of experience helping patients fight insurance denials for bariatric surgery.
A Free Assessment Comes with Free Advice, and Another Chance
Unfortunately, because Donna had already gone through the entire appeals process with the insurance company, the insurance company was right in saying she had exhausted her options. But what Donna didn’t know, and what Kelley explained to her, is that Donna’s surgeon’s office could submit a new request to the insurance company.
Kelley gave Donna some tips on how to maximize her chances of getting approved, but also told her that the insurance company may still deny coverage even if she did everything right. If that happened, Kelley told Donna, PRIA Appeals could help fight the appeal. Donna went back to her surgeon, told them what needed to be done and, just as Kelley predicted, her surgery was denied again. But this time Donna knew what her options were. She retained PRIA Appeals to handle her case and we were able to get her approved after a successful appeal to an independent reviewer with the authority to overturn the plan’s denial.
There are two morals we can take away from this true-life story:
1) Don’t give up! So many patients have to pay out of pocket or give up on getting bariatric surgery because their insurance company denied coverage for the procedure. Don’t be one of those people! Fighting an appeal is your right, and there’s a good chance you’ll succeed.
2) PRIA Appeals is here to help! We are dedicated to helping patients get the medical care they need and will help any way we can, whether that’s offering tips as part of our free consultation or taking on your case to fight for your rights. We are in your corner!
Contact PRIA Appeals to Schedule a Free Assessment
If you have been denied insurance coverage for a necessary medical treatment or procedure, PRIA Appeals can help!