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Gastric Bypass Surgery – Requesting Insurance Pre-Approval

December 24, 2011 by  
Filed under Finance

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:

1. A letter of medical necessity from your primary care physician or a medical specialist recommending you for weight loss surgery
2. 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)
3. A well-documented list of any serious health issues, such as hypertension or diabetes, considered a direct result of severe or morbid obesity
4. A detailed list of any doctor-prescribed medications for weight loss
5. Supporting documents pertaining to any medically-supervised diet programs
6. Evaluation records and clearance if under the care of a mental health specialist or if taking psychotherapeutic medication, such as anti-depressants
7. 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 yourself and your physician or surgeon, and attach all supporting documentation. You may also want to send your letter via registered or certified mail, so you can mark the date when your request was filed and have proof that it was received.

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