Bariatric Surgery Insurance Appeal

For any of you that might be pre-op or know those that are this could be an awesome resource from WLSHelp.com should insurance deny your bariatric surgery……..APPEAL!

 


Appealing a Medical Necessity Denial – Patient’s Letter

If you requested pre-authorization for bariatric surgery and receive a denial, APPEAL. As there is usually a time limit to respond, it is important to appeal within a timely manner, but it is also important to respond effectively. When appealing, write a letter that is factual and persuasive, yet pleasant and polite. Keep in mind your goal – approval for weight loss surgery.

Your appeal letter should include:

  • Patient Identification – information used to identify your case, such as your name, policy number, group number, claim number
  • Reason for denial – restate reason for denial as explained in denial letter
  • Brief health history – patient statement of history with obesity, health conditions, previous weight loss attempts, and why bariatric surgery is a necessary treatment
  • Information to correct errors – if it appears the denial was made because of an error, state the correct information, such as wrong surgery or procedure coding error
  • Why you disagree with denial – tell the insurance company why you disagree with their decision, whether due to incorrect or incomplete information, and provide specific, factual information that supports approval of weight loss surgery for treatment
  • Purpose of letter – what you are requesting in your appeal, i.e. that the insurer reconsider the denial and approve coverage for the procedure in a timely manner

Sample Patient Appeal Letter for Bariatric Surgery

(Date)

(Name of Contact Person at Insurance Company)
(Insurance Company Name)
(Address)
(City, State ZIP)

Re: (Your Name)
(Group Number/Policy Number)
(Case Number/Claim Number)

Dear (Name of Contact Person at Insurance Company),

I am writing this letter to appeal (insurance company name) decision to deny coverage for (name of the specific procedure denied). Based on the letter of denial dated (insert date), this procedure was denied because “(quote specific reason for the denial as stated in denial letter).”

To review my health history, I was diagnosed with (list medical conditions) on (dates). My previous methods of weight loss treatment include (list treatments). At this time, my doctor (name of doctor) believes that (state name of procedure) is medically necessary and will significantly benefit my health. I have also enclosed a letter from my doctor, (doctor’s name), that discusses my medical history in more detail.

As you may have based your denial on incorrect or incomplete information, I wanted to provide the following information that shows why I disagree with your denial and why I believe (name of procedure) should be approved.

  • (Provide specific facts to support weight loss surgery and counter reasons of denial, including medical studies, medical articles, and other information that shows that procedure resolves and improves your diagnosis).

Based on this information, I am asking that you reconsider the denial and approve coverage for (name of procedure). My doctor has scheduled surgery for (date). If you need any additional information, please contact me at (telephone number).

Thank you for your time and attention to this matter.

Sincerely,

(Your name)
(Your address)
(Your City, State ZIP)
(Your telephone number)

Tips for the Appeals Process

  • Keep copies of all correspondence you receive from the insurance company, including denial letter(s) and approval letter
  • Make copies of all correspondence you send to the insurance company, including letters, health history, medical files, doctor’s letters
  • Keep a written record of all contact and phone calls with the insurance company
  • Send all correspondence to the insurance company via certified mail with return receipt
  • Be persistent! – The appeals process can take a lot of work, but don’t give up. Many people have been successful in winning insurance approval for weight loss surgery with persistence and proper documentation.

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2 Responses to Bariatric Surgery Insurance Appeal

  1. Tammy says:

    My insurance company covers bariatric surgery but denied me due to the fact that my BMI was 35 or greater for the previous 3 years. I was so down when they denied me. I figured there was no hope once they say no. I had a pity party for myself for a couple weeks and then decided to appeal. They had already said no so I figured I didn’t have anything to lose by trying. I did some searching on the web and found your site with a sample appeals letter. I also got a copy of the medical records/history that had been sent to the insurance company. I started looking through them. I couldn’t really read them that well since they were all in cm, kg, etc. By searching on the web for kg to pounds and cm to inches, I was able to convert my height and weight. I noticed the doctors office had my height flunctuating from 5’7″ – 5’9″ when I am really only 5’6″. This threw the calculations off by 2 or 3 bmi points. In order to backup my real heighth, I got my records from my OB/GYN. I attached those records along with all the other records plus a spreadsheet with their calculations plus the actual calculations with my real height. I was then able to use the sample appeals letter to plead my case. I left all of the feelings out of it and based it on facts. I was so happy to receive a call 9 days later that the insurance company is going to cover my surgery. I can’t believe it! I have hope again! I hope this will help someone else. Don’t give up! Like they say…don’t be afraid to appeal their decision.

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