Insurance Approval for Weight Loss Surgery Massachusetts

One of the happier moments in your weight loss surgery journey is when you get the seal of approval from your insurance company.

Most insurance companies realize the long-term effects and cost savings associated with the weight loss that occurs after patients have weight loss surgery. For example, if you have diabetes, your insurance company will spend thousands of dollars covering your medications and treatment. Paying for one gastric bypass procedure is likely less expensive for the insurance company than paying for your diabetes medications and treatment for the rest of your life (not to mention paying for any other complications that may arise down the road as a result of your obesity).

Unfortunately, obtaining insurance approval is not always easy. Acquiring insurance coverage for weight loss surgery can be a major obstacle to finally achieving a healthier body and life. Over the past few years, insurance carriers have seen a significant increase in the demand for weight loss surgery procedures. According to the American Society for Bariatric Surgery (ASBS), 16,200 weight loss procedures were performed in 1994. Ten years later, in 2004, an estimated 140,640 surgeries were projected to take place — that's more than an 800 percent increase! The average cost for surgery is now approximately $25,000. Due to this increase in procedures and cost, some insurance companies are making it more difficult for patients to obtain approval. These insurance companies don't view their policyholders as long-term responsibilities and figure their customers will switch carriers before they can recoup their investment.

So what hurdles will you have to cross? Most companies require what's called a letter of medical necessity from your bariatric surgeon and your primary-care physician. The following information is generally what's required in this preauthorization letter:

• Your height, weight history, and body mass index (BMI)

• A description of your obesity-related health conditions, including records of treatment

• A detailed description of the limitations your obesity places on your daily activities

• A detailed history of the results of your dieting efforts, including medically- and non-medically-supervised programs

• A history of exercise programs, including receipts for memberships in health clubs

Ask your doctor to include information from medical journals regarding the effectiveness of weight loss surgery, especially information demonstrating the control or elimination of obesity-related health conditions.

Many carriers also require a nutritional consult and psychological evaluation. Your surgeon will take care of referring you for these consultations.

A number of carriers now require detailed documentation of participation in a physician-supervised diet. Most require the submission of at least six months' worth of office notes from the supervising physician, including proof of dietary supervision and recorded weigh-ins.

Not all primary-care physicians support weight loss surgery. Your physician may not be up to speed on the latest techniques and safety reports; he may only be familiar with older procedures that had higher risks. Don't be discouraged. You can bring information to your doctor to try to change his opinion. If your primary-care physician cannot be persuaded, you may have to find another primary-care doctor who understands the necessity for your surgery.

Request letters and documentation from any medical professionals who treated you for health-related conditions caused by or aggravated by obesity. Make sure all the letters are sent directly to you (as opposed to your doctor's office), so you can determine if they're supportive of your case. Be sure to make copies of the letters for your records. In addition, forward to your surgeon anything that documents difficulties related to morbid obesity such as:

• High blood pressure

• Diabetes

• Cardiovascular disease

• Sleep apnea

• Gastroesophageal reflux

• Infertility

• Arthritis

• Dyslipidemia (a disease characterized by a high concentration of lipids and cholesterol in the blood; a risk factor for heart disease and cardiovascular disease)

• Urinary stress incontinence

• Other obesity-related conditions

Other important information to provide your surgeon includes

• Your weight history, demonstrating a history of morbid obesity

• Your current medications

• Your psychiatric history

• Your musculoskeletal history, like joint pain, bone fractures, and osteoarthritis

• Any allergies you have

Each weight loss surgeon's practice has its own way of managing financial and insurance issues. Someone in the office should be able speak to you about your insurance concerns and questions. Most of these advisors are familiar with the ins and outs of working with specific carriers.

Being familiar with your own policy is still important. Even the most well-informed advisor won't know all the details of your specific policy without some investigation.