Friday, April 12, 2024

Reasons To Be Denied Weight Loss Surgery

Should I Use Insurance Or Cash To Pay For Surgery

1000lb Sisters – Chris Denied Weight Loss Surgery?

Insurance is typically the best way to go when you are considering weight loss surgery. However, many procedures are not covered by insurance. Historically, gastric sleeves, duodenal switches, mini-gastric bypasses and other experimental procedures are not covered. Today gastric sleeves, laparoscopic gastric bypass and lap gastric bands are typically covered by most major insurance companies. But this doesnt necessarily mean your policy includes coverage.

It depends on your policy not the insurance carrier.

While most insurance carriers offer some sort of weight loss surgery coverage, your individual policy details whats included and whats not. Some policies specifically exclude weight loss surgery. Most insurance companies charge more to include weight loss surgery coverage. For this reason, you will want to check your policy to see if you have coverage. The best way to do that is to call your carrier directly .

You can also call a couple of local bariatric surgeons and their staff will check to see if you have coverage. Use our surgeon finder to find a bariatric program in your area.

Youre covered!

If you have coverage, then its time to find a surgeon. We recommend attending a couple of seminars and meeting with at least two different bariatric surgeons. This article will walk you through choosing a great bariatric surgeon.

I dont have coverage.

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  • What Will I Weigh After Gastric Sleeve

    The amount of weight you lose is dependent on a number of factors, including your current weight, gender, and health. On average, patients who follow the Sleeve Clinics surgical aftercare program can expect to lose approximately 1.5 to 2 pounds per month after surgery. The time it takes for your body to return to its pre-surgery weight varies from person to person.

    Why Wouldnt I Qualify For Bariatric Surgery

    When patients finally arrive in our office ready to commit to the life change that is bariatric surgery, they are often raring to go and want to have surgery as soon as possible. Years of dieting, exercising, weight loss programs and more are so exasperating that surgery feels like a breath of fresh air and excitement. So, when the news comes back that there may be a hiccup in their qualification for bariatric surgery, it can be downright depressing. But why might a patient not qualify for bariatric surgery?

    BMI: First and most obviously, they simply may not have a BMI that is high enough. A BMI of 35 or more with one or more obesity related conditions or BMI of 40 or greater regardless of obesity related conditions is required to have surgery. This is a hard and fast rule ensuring the patient truly does need bariatric surgery and cannot benefit from other interventions.

    Health Concerns: Surgery puts significant strain on the body. Both the surgical intervention and anesthesia come with risks, and patients in poor general health increase those risks dramatically. That is why we perform a number of pre-operative tests to ensure this risk is as low as possible.

    Smoking: Smoking is a recipe for complications during and after surgery. Patients must be able to quit smoking at least six weeks before the procedure.

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    Can I Buy Insurance To Cover Bariatric Surgery

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    Bariatric surgery can be covered by both private commercial and government-sponsored insurance programs, says Dr. Garber. However, there are no special types of insurance that will cover this type of procedure. If you intend to undergo weight loss surgery, but your current policy does not cover it, you have the option to enroll in a new policy during open enrollment that does provide coverage for bariatric surgery.

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    Continue Learning About Weight Loss Procedures And Surgeries

    Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.

    Private Weight Loss Surgery

    The cost of private weight loss surgery can vary.

    Typical prices are:

    • gastric band surgery £4,000 to £8,000
    • gastric bypass £8,000 to £15,000
    • sleeve gastrectomy £8,000 to £10,000

    You may not need a referral from a GP for private treatment, but it’s a good idea to speak to one for advice first.

    Before approaching a private clinic or surgeon, do as much research as possible into the different types of weight loss surgery and think about the questions you want to ask.

    Some people consider having treatment abroad, where costs for private treatment can be cheaper, but make sure you weigh up any potential savings against the potential risks.

    Standards may not be as strict in clinics outside the UK, and aftercare is not always straightforward. Clinics in other countries may not provide follow-up care, or it may not be the same standard as in the UK.

    Page last reviewed: 14 April 2020 Next review due: 14 April 2023

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    Age Limit For Lap Band Surgery

    Gastric band surgery is relatively less invasive, which makes it easier to qualify for this procedure. The lower age limit for lap band surgery would generally be 13 or 14 years, while there is no specific upper age limit. However, some insurers may not give lap band surgery approval because of the relative inefficacy of the procedure. This could be one of the reasons insurance companies deny bariatric surgery if the policy terms exclude a particular type of procedure.

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    Exclusions For Weight Loss Surgery

    There are people who for a variety of reasons are not suitable for obesity surgery. When deciding upon suitability your health comes first and your surgeon will consider the risks posed by excessive weight gain against the surgery. If the surgery is likely to endanger your health or the long term health risks outweigh the benefits then you will not be considered.

    There are a list of contra-indications to surgery which may mean that you are not suitable for surgery. If any of the following items apply to you it does not mean that you are disqualified from surgery: just that you are in a higher risk category than someone else.

    These are as follows:

    • Drug and/or alcohol addiction.
    • Age under 16 or over 75.
    • History of heart disease or severe lung problems. These can put you at increased risk during anaesthesia.
    • Chronic pancreatitis .
    • Cirrhosis of the liver.
    • Autoimmune disease such as systemic lupus erthyematosus.
    • Blood disorder which increases your risk of heavy bleeding.
    • History of severe psychiatric illness.

    However, there are four items in this list which if they apply to you mean that you are not suitable for obesity surgery. They are:

    • Receiving cancer treatment .
    • Suffer from Crohns disease or ulcerative colitis .

    Cigna Bariatric Surgery Requirements

    In order to qualify for the Cigna weight loss surgery, you will need to meet the following Cigna bariatric surgery requirements 2019:

    • You must be 18 years of age or older.
    • You must have a BMI of more than 40 for at least the past 2 years.
    • You must have a BMI of 35-39.9 for at least the past 2 years, and you must have at least one obesity-related illness.
    • You must have participated in a medically-supervised weight loss program within the last 2 years.
    • Your doctor must deem the bariatric surgery a medical necessity for you.
    • You must have a psychological evaluation that shows you are capable of changing your lifestyle for weight loss.

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    Appealing A Medical Necessity Denial

    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

    What To Do If Youre Denied

    Organic or Plastic? Anerlisa

    A pre-approval does not necessarily guarantee coverage and we will help you in any way possible to ensure that your coverage is not denied. Sometimes, however, patients will receive a denial anyway. This is when you should first contact your insurance provider and request the denial in writing, with the reason clearly stated. Second, bring this denial to our bariatric coordinator and we will help you analyze it and submit a response or appeal.

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    How To Get Your Health Insurer To Pay For Your Weight

    John is the editorial director for, and Before joining QuinStreet, John was a deputy editor at The Wall Street Journal and had been an editor and reporter at a number of other media outlets where he covered insurance, personal finance, and technology.

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    Quality Verified

    At, we are committed to providing honest and reliable information so that you can make the best financial decisions for you and your family. All of our content is written and reviewed by industry professionals and insurance experts. We maintain strict editorial independence from insurance companies to maintain our editorial integrity, so our recommendations are unbiased and are based on a comprehensive list of criteria.

    Even if your body mass index classifies you as morbidly obese that doesnt mean your health insurance company will approve bariatric surgery. Its more complicated than that.

    Theres no doubt that Americans are getting heavier. According to the Centers for Disease Control and Prevention, adult obesity rates doubled in the past 30 years. Nearly 40% of adults are considered obese. At least 20% of adults in every state are obese.

    Bariatric surgerys benefits far outweigh the risks. Surgery can increase life expectancy by up to 89%, according to Insure.coms 2021 report. And after surgery, patients fare far better than they would have without it.

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    Key Takeaways

    What Does Your Bmi Have To Be For Insurance To Cover Weight Loss Surgery

    Obesity is defined as a score of 40 or more. If you have a body mass index of 35 or greater, and have a number of health problems like high blood pressure, heart disease, or type 2 diabetes, you may be able to get a surgery. Bariatric surgeries are not without risks. The most common complications are bleeding, infection, and scarring. Bleeding can occur in the first few days after surgery, but it usually goes away on its own within a few weeks.

    Infections are more likely to occur if the surgery is performed in a hospital setting. Scarring is a result of the weight loss resulting from surgery. It can range from minor to severe, depending on the type of surgery and the amount of weight lost. If you lose too much weight, you may need to lose more weight to restore your body to its original size.

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    Lobby Hr On Your Own Behalf

    Some companies and health insurers cover bariatric surgery on a case-by-case basis. That means you may have to ask if you hope to receive. If your company doesnt offer coverage at all, put a presentation together and educate your HR department on the benefits of weight loss surgery.

    You might mention that healthier employees are more productive and happier when coming to work. Healthy employees work harder and require fewer sick days. The company could save money and receive a boost in productivity by making bariatric surgery an option.

    If all else fails, there are other ways to pay for bariatric surgery.

    Does Insurance Cover Lap Band Surgery

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    Yes, most insurance policies that cover weight loss surgery provide partial or full coverage for gastric lap band procedure. But you should contact your insurer directly to know whether lap band is covered by insurance.

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    Can I Be Denied Weight Loss Surgery

    Many patients who seek weight loss surgery are denied an operation because of insurance barriers, psychological concerns, and poor medical fitness for surgery. The aim of the study was to study the causes and outcomes of patients denied surgery in the United States. We used data from the National Health and Nutrition Examination Survey 19992002 to examine the reasons for denial of surgery and the characteristics of the patients.

    Of the 2.5 million patients aged 18 years who were denied surgery, 1.2 million were obese and 3.3 million had a BMI of 30 or higher. The most common reason for denying surgery was a lack of financial resources, followed by concerns about the operation itself , the patients medical condition or the surgeons ability to perform the surgery .

    These data suggest that patients with obesity are more likely than those without obesity to be denied a surgical procedure.

    What To Do In The Meantime

    The time waiting for the pre-approval does not have to be wasted. After your first consultation, you will learn more about what to do before surgery and the whole process a lot easier. You can begin your diet and exercise regimen, stop smoking and start to lose a bit of weight to make surgery safer. By the time you receive the insurance companys decision, youll have completed many of our prerequisites for surgery as well.

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    How Do I Get Approved For Bariatric Surgery

    Dealing with insurance approval and rejection and appeals and denials creates a roller-coaster of emotion. Let the experts do their part. Your surgeon should have an in-house expert that will contact your insurance and start the process for approval.

    Do not assume that your job is finished after youve been approved!

    Make sure you are staying on top of your duties and appointments. There will be many. Keep documented records of everything and check in with the specialist regularly.

    This is also a great time to change bad habits. Youre on your way to getting a life-changing procedure. Start changing your eating and exercising habits now or the change after surgery will be harder to make. Remember, surgery does not guarantee success. In fact, if you dont change your habits, even though youve had weight loss surgery you will fail. And surgery is actually easier for the surgeon if youve lost some weight before surgery. This decreases the size of your liver which makes it easier during the operation and it decreases your risk of complications due to anesthesia.

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