What kinds of weight loss surgery appeal cases do you handle?
We accept cases for denials of all recognized forms of weight loss surgery including:
- Roux-en Y (RNY) Gastric Bypass
- Vertical Sleeve Gastrectomy
- BPD/DS (Duodenal Switch)
- All types of revisions and conversions such as:
- VSG to RNY for GERD
- Remove failed LAGB and convert to alternative procedures (RNY; BPD/DS; VSG)
- Conversion or revisions due to weight regain
What is an authorized representative?
With any health insurance plan, you are entitled to designate an authorized representative to help you appeal an insurance denial, and your insurance company is obligated to work with that authorized representative on the matter. Appeals are not legal proceedings, so you do not have to hire a lawyer to be your authorized representative. If you work with PRIA Appeals, you will designate us as your authorized representative and we will work with the insurance company on your appeal and advocate on your behalf.
When should I contact PRIA Appeals?
If you have been denied coverage for a medical treatment or surgery, contact us as soon as possible. The sooner we get involved, the better we can advocate for you. You can even contact us before you have been denied if you are unsure about the process or worried you may be denied. We can help then too.
Shouldn’t my bariatric surgeon’s office be doing this appeal?
A provider’s rights to appeal are somewhat more limited than that of a patient, and many providers don’t feel comfortable with the process, especially since they may not have been involved in some elements of your case, such as a psychological or nutritional evaluation. Your bariatric provider specializes in surgery, not fighting with insurance companies—that is our specialty! If your provider refers you to us, they are doing so to give you the best chance of winning your appeal. Rest assured that we will work directly with your providers throughout the process to be sure everyone is on the same page.
I had weight loss surgery some time ago, but now I need a revision. Can you help me?
Absolutely! Regardless of whether you need to have the same procedure revised or fixed (e.g., repairing a dilated anastomosis or stoma in RNY gastric bypass), or you need to have your first procedure “converted” to a new procedure (e.g., converting an adjustable gastric band to a sleeve gastrectomy), or adding a second bariatric procedure to your first (e.g., placing an adjustable gastric band “over” a RNY gastric bypass), we can help you when your insurance company says “No.”
Unfortunately many insurance companies and self-insured plans attempt to limit patients to “one surgery per lifetime” or deny revision procedures based on their belief that you were “non-compliant” with your treatment plan after your first procedure. Regardless of the reason your insurance company gives for a denial, contact us so we can evaluate how we may be able to assist getting that revision approved.
I had surgery and now all of the excess skin I have is causing health problems, but the insurance says it is cosmetic and not medically necessary. Can you help me fight that?
Yes! Reconstructive surgery, including removing excess skin, is often medically necessary after massive weight loss. We can also work with your reconstructive surgeon’s office to help them tailor their request for coverage to the insurance company in a way that maximizes your chances of getting approved.
How much is this going to cost me?
Our fees vary depending on the extent of service you need, but they are surprisingly affordable. All of our appeal services are performed on a fixed fee basis rather than an hourly rate based on our time spent on the appeal, so you know exactly how much you have to pay up front. We are happy to work with you so that fees are never an obstacle to you getting the help you need.
Can you help me get money back if I have already had surgery as a cash pay patient?
Yes! If you paid cash for a procedure that was wrongly denied by your insurance company or self-insured plan, we may be able to get you some or all of your money back.
Can I appeal if my managed care plan won’t even approve a referral to see the bariatric surgeon?
Yes! While most denials stem from a bariatric surgeon or program’s request for approval after they have determined a patient is a candidate for surgery, there are times when a patient cannot even get in to see the surgeon to have that evaluation done because the insurance company requires a referral to the surgeon and that referral is being denied. We can help get you to the surgeon so they can make the medical determination if weight loss surgery is right for you—after all, they are the experts and you should not be denied access to them!
Can you help me if my insurance says it doesn’t cover any type of weight loss surgery?
You would be surprised how many times people are told they have an exclusion for surgery, but when we review their certificate of coverage or other insurance documentation, no such exclusion exists. Even if your policy includes contract language such as, “We don’t cover any form of weight loss surgery,” we may still be able to help. As part of our free consultation with you, we will evaluate your case and review the contract language to determine if we think we can help. We will always tell you the truth, and will not accept your case if we don’t think we have a reasonable chance of helping you.
My bariatric program’s insurance person says I must do a 6-month medically supervised diet because it is required by my insurance company. Is that true?
No! Most surgeons’ offices mean well, and try to avoid denials by complying with insurance company criteria, but in some cases it can be too risky to wait 6 months. First, your health may suffer if your comorbid conditions worsen or you develop more of them. Second, there is the chance your insurance plan or coverage may change while you are on their mandatory supervised diet. If your plan changes to an exclusion of all surgery, you may lose out on any chance to get approved.
There is little medical evidence to support these supervised diets over 6-12 months. Here is what the American Society of Metabolic and Bariatric Surgeons (ASMBS) says in its Position Statement on Preoperative Supervised Weight Loss Requirements:
“It is the position of the ASMBS that the requirement for documentation of prolonged preoperative diets efforts before heath insurance carrier approval of bariatric surgery services is inappropriate, capricious, and counter-productive given the complete absence of a reasonable level of medical evidence to support this practice. Policies such as these that delay, impede, or otherwise interfere with life-saving and cost-effective treatment, as have been proven to be true for bariatric surgery to treat morbid obesity, are unacceptable without supporting evidence.”