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Why Do Insurance Companies Deny Coverage for Bariatric Surgery?

For many people, bariatric surgery is the best option to improve their health and reduce a variety of comorbid conditions. Unfortunately, even though weight loss surgery is a widely used and proven successful treatment, insurance companies may still deny coverage for the procedure.

In many cases insurance can deny coverage for bariatric surgery even when it is a viable treatment option recommended by a doctor.

Here are the four most common reasons to be denied weight loss surgery by insurance companies, what those reasons mean, and what you can do about it.

Denial Reason #1: Bariatric surgery is excluded from your insurance contract.

What this denial means: If your insurance company gives “contract exclusion” as the reason to deny coverage for bariatric surgery, they are saying your insurance plan excludes bariatric surgery, so it is not covered even if your doctor recommends the procedure.

What you can do: Don’t just accept the word of your insurance company! In many cases, our clients have been told they have an exclusion for surgery, but when we review their insurance documentation, no such exclusion exists. Ask an expert to review the contract language to verify that what the insurance company has told you is correct. In some cases, even if your contract actually does exclude weight loss surgery, it may be worth challenging the contract exclusion. It is possible to successfully appeal an insurance denial based on contract exclusion if the contract has been poorly worded, or if the surgery may be an appropriate treatment for other conditions such as GERD or type 2 diabetes.

Denial Reason #2: Your bariatric surgery is not medically necessary.

What this denial means: Even if your doctor says bariatric surgery is medically necessary in your case, an insurance company may still claim you don’t really “need” the procedure, and therefore they will not cover it. While the American Medical Association has a standard definition for the term “medically necessary,” every insurance company has its own definition of what “medically necessary” means.

What you can do: It can be difficult to understand how your insurance company defines “medically necessary” and to challenge that definition to get them to cover your bariatric procedure. PRIA Appeals has a team of experts that can challenge a “not medically necessary” insurance denial on your behalf and get you the care you need.

Denial Reason #3: Your weight loss surgery is an experimental or investigational treatment.

What this denial means: The weight loss surgery recommended by your doctor may utilize newer devices or procedures (balloons, SADI-S, etc.) that are not yet considered “mainstream medical treatment.”

What you can do: Contact an expert. PRIA Appeals has many years of experience supporting innovative medical treatments and preventing insurance companies from using experimental/investigational denials to prevent patients from gaining access to the care they need.

Denial Reason #4: Your plan does not cover revisions or conversions.

What this denial means: You may receive a coverage denial if you have already had weight loss surgery, but you need a second surgery (called a revision or conversion procedure) to address insufficient weight loss or complications from the first surgery. Insurers frequently deny coverage for revisions or conversions even if those complications are serious or potentially life-threatening.

What you can do: Insurers may give several different reasons for this type of denial, including claiming that your plan only covers one weight loss surgery per lifetime, that you were not in compliance with a follow-up program, that there is no proof that the first procedure needs to be corrected or replaced, or that you no longer meet the requirement used for your first weight loss surgery. This denial can be a difficult one to fight, and it can help to have an expert in your corner.

PRIA Appeals has experience fighting and overcoming insurance denials based on revisions or conversions. We can help get you the second chance you deserve! Contact PRIA Appeals to schedule a free assessment today.