Gastric Bypass Surgery - Requesting Insurance Pre-Approval
- By:Anil Kumar Pammidimukkala
You have done your research on gastric bypass surgery, and
determined whether your insurance carrier will pay for the procedure. You have
the CPT/ICD-9 codes memorized, and you’re on a first-name basis with the member
services rep at the insurance company. You have prepared the documentation
required by your carrier, and the big day is finally here: It’s time to submit
all this information with a request for pre-approval of your gastric bypass
procedure.
Increase Your Chances of Insurance Success
The checklist below can help you ensure you have obtained
everything needed to increase your chances of securing preauthorizing for
weight loss surgery from your insurance carrier:
- A letter of medical necessity from your primary care
physician or a medical specialist recommending you for weight loss surgery - Doctor’s records of office visits documenting your
history of obesity (this should include documentation supporting The National
Institute of Health guidelines of severe and morbid obesity) - A well-documented list of any serious health issues,
such as hypertension or diabetes, considered a direct result of severe or
morbid obesity - A detailed list of any doctor-prescribed medications for
weight loss - Supporting documents pertaining to any
medically-supervised diet programs - Evaluation records and clearance if under the care of a
mental health specialist or if taking psychotherapeutic medication, such as
anti-depressants - Records of any tests requested by your insurance company
and their results
Submitting Your Request
After verifying that you have gathered all required
documents, the office of your gastric bypass surgeon or your primary care
physician will likely assist you in submitting a request for preauthorization.
You may also submit the information yourself, but your request will likely be
given more weight if coming from a medical practitioner.
Along with your required documents, the letter to
your insurance company from your doctor will contain pertinent information to
help in the pre-approval process. This correspondence should clearly identify
the date, your name, and the reason for the letter (e.g., “request for
preauthorization”). Your date of birth, insurance number, and group number
should come immediately after this information, after which the body of the
letter should follow.
Making Your Case
Within the body of the letter, your doctor should again state your name, along
with your age and gender, and the long-term medical problem for which you are
requesting coverage of treatment—in this case, severe or morbid obesity.
The body of the letter should also include your weight and
height, and note that your body mass index (BMI) is excessive for the criteria
of obesity. In addition, your doctor should state clearly that if the weight
problem continues, you would suffer from serious health risks, resulting in a
shorter life span. The following are other topics that should be addressed in
your request for preauthorization:
- The specific period of time you have been in your
doctor’s care expressly to manage your obesity. - Details of your active involvement in recommended diet
or medication remedies. Include the amount of weight lost in following these
recommendations and show that you have suffered from continued weight gain
after trying these programs. - The current list of medical conditions directly
resulting from weight issues, and assurance that these issues would improve
greatly upon shedding the excess weight following gastric bypass surgery. - The procedure expected to take place, the surgeon expect
to perform the procedure, the address and telephone number of the surgeon or
bariatric treatment center, and the expected length of hospital stay. - A description of the surgery, including details of the
benefits you seek to gain from
gastric bypass surgery.
Prior to sending the request, be sure to make copies for- A letter of medical necessity from your primary care