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How to get your health insurer to pay for your weight-loss surgery

weight loss surgeryThere's no doubt that Americans are getting heavier:  According to a 2009 report by the Trust for America's Health, adult obesity rates have doubled in the past 30 years, and nearly two-thirds of states have adult obesity rates exceeding 25 percent. Worst off is Mississippi, where nearly one in every three adults are obese.

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Some overweight people have turned to bariatric surgery when diets and exercise failed them in dropping weight – excess weight that could cause them major health problems. Bariatric surgery encompasses operations on the stomach such as gastric bypass (open and laparoscopic), laparoscopic adjustable gastric banding, and biliopancreatic diversion. These procedures dramatically restrict one’s ability to eat, thereby causing weight loss. Those who undergo these procedures wind up with a smaller stomach that's able to hold only a few ounces. Eating too much can make that person feel ill.

In addition, some weight-loss surgeries alter the digestion process, limiting absorption of calories and nutrients.

The benefits of surgery

According to the American Society for Metabolic & Bariatric Surgery (ASMBS), the mortality rate for bariatric surgery is about 0.1 percent, but those who have the surgery can increase their life expectancy by up to 89 percent. And after surgery, patients fare far better than they would have without it. A 2007 study reported in the New England Journal of Medicine showed that among gastric bypass surgery patients, death from diabetes was reduced by 92 percent, death by coronary artery disease was reduced by 56 percent, and death by cancer was reduced by 60 percent.

Your doctor may recommend surgery to help you lose weight if you have a body mass index (BMI) of more than 40 or a BMI of 35 or more coupled with an obesity-related disease like Type 2 diabetes, heart disease or sleep apnea. A BMI of 25 to 30 is considered overweight and 30 to 35 is considered obese. A person who is morbidly obese typically has a BMI above 35.

Will insurance pay?

The cost of obesity

Each year, obesity costs the nation more than $117 billion in medical costs and lost productivity. This includes $3.9 billion in lost productivity due to obesity among Americans age 17 to 64.

People who are obese spend $395 more on medical care per year than non-obese people. Obese individuals see an increase of 36 percent on health care services and 77 percent on medications than those in a normal weight range. The increase in costs associated with medical services to treat obesity and obesity-related conditions is higher than with other studied conditions, such as aging from 30 to 50, smoking and problem drinking.

Source: ASMBS, Health Affairs

The average bariatric surgery costs $17,000 to $26,000, according to the ASMBS. Even with your doctor’s recommendation and coverage available from your health insurance policy, your health insurer might not pay for the surgery. According to ASMBS, “insurance denial and unattainable prerequisites were the two most common reasons why some patients do not undergo laparoscopic gastric bypass surgery” and about 25 percent of patients considering bariatric surgery are denied coverage three times before getting approval. If you’re considering bariatric surgery and want your health insurance to pay for it, you may have to jump through a few hoops.

It's common to find health insurance companies that will not pay for weight-loss surgery, yet these same insurers are paying for years of treating the conditions associated with obesity. Mounting evidence shows that surgery for morbid obesity can be more cost-effective than treating the conditions resulting from obesity. Dr. Neil Hutcher, a practicing bariatric surgeon in Richmond, Va., and past president of ASMBS, sees conditions such as diabetes and heart disease as "rooms in the house of obesity." Hutcher observes, "Health insurers treat each room in the house, but the roof is falling in."

It’s highly unlikely that you'll find an individual health plan that covers weight-loss surgery, especially if you're already overweight. Your best chance for attaining insurance coverage for weight-loss surgery is through a group health plan. But standard health plans do not cover bariatric surgery; an employer must specifically select it as an option.

Only six states mandate that treatment for morbid obesity be covered by group health plans: Georgia, Illinois, Indiana, Maryland, New Hampshire and Virginia. These mandates apply only to group plans, and even then not to group plans offered by self-funded companies. That’s where large employers take on their own financial risk of covering employee claims, and you probably won’t know if your employer is self-funded unless you ask.

Finding a good
bariatric surgeon

 The American Society for Metabolic and Bariatric Surgery certifies "Centers of Excellence" around the country. To qualify, the hospital or institution must perform at least 125 bariatric surgeries per year collectively and the individual surgeon must have performed at least 125 bariatric surgeries and perform at least 50 per year.

The center must also report long-term patient outcomes and have an on-site inspection to verify all data. In addition, the center must have a dedicated multi-disciplinary bariatric team that includes surgeons, nurses, medical consultants, nutritionists, psychologists and exercise physiologists.

To locate a bariatric surgery Center of Excellence near you, visit SurgicalReview.org.

The Council for Affordable Health Insurance estimates that mandated obesity coverage adds 1 to 3 percent to premium prices.

What you’ll need to make a claim

Know your policy terms before you schedule surgery. Is obesity surgery specifically excluded in your policy? Do you need pre-authorization?

Your insurer will likely require a full medical work-up along with the pre-authorization request plus documented physician-supervised weight-loss attempts. However, weight-loss programs themselves are rarely covered by insurance, and Weight Watchers and Jenny Craig don't count.

You'll find out exactly what documents you need when you make a pre-authorization request from your insurer; expect it to involve volumes of paperwork.

Coverage for weight-loss surgery varies widely, as do insurers’ definitions of “medically necessary.” Here’s a sampling:

Aetna

Aetna does not offer any individual health plan that covers bariatric surgery. Most Aetna group HMO and POS plans exclude coverage of surgical operations, procedures or treatment of obesity unless approved by Aetna.

For Aetna plans that do cover bariatric surgery, here is a summary of the criteria for gastric bypass approval:

The patient must have been morbidly obese for at least two years, with a BMI of 40 or more or have BMI greater than 35 in conjunction with any of the following: coronary heart disease, Type 2 diabetes mellitus, clinically significant obstructive sleep apnea or medically refractory hypertension. In addition to that, you’ll have to:

  • Have attempted weight loss in the past without successful long-term weight reduction; and
  • Have participated in a “physician-supervised nutrition and exercise program” or a “multidisciplinary surgical preparatory regimen,” each with their own criteria.

The full list is available on the Aetna Web site under Clinical Policy Bulletin: Obesity Surgery.

CIGNA HealthCare

Bariatric surgery is specifically excluded under the standard CIGNA HealthCare plan, but employers can elect to include or exclude coverage for bariatric surgery in their group health plans. Some health plans may fall under state mandates for bariatric surgery.

When CIGNA coverage is available, a patient is required to have:

  • Reached age 18 or full skeletal growth.
  • A BMI of more than 40 for at least the past 24 months or a BMI of 35-29.9 for at least the past 24 months plus another significant problem, such as diabetes or hypertension.
  • Active participation within the last two years in a physician-directed weight-management program.
  • An evaluation within the past 12 months including: an evaluation by a surgeon qualified to do bariatric surgery recommending surgical treatment, a separate medical evaluation recommending bariatric surgery, clearance for surgery by a mental health provider, and a nutritional evaluation by a physician or registered dietician.

CIGNA HealthCare also covers medically necessary reversal for bariatric surgery when a patient has complications and, under certain circumstances, covers revision of a previous bariatric procedure when the patient has not lost adequate weight.

How denials are dealt out

health insurance denialsEven if you're lucky enough to have bariatric surgery coverage in your policy, brace yourself for a possibly long claims process. At best, you'll need mounds of documentation to show the surgery is medically necessary for you.

Or you may run into big roadblocks. Hutcher says he has witnessed a "hostile environment" for claims and describes three main ways that health insurers deny claims for bariatric surgery:

  1. By contractual denial, meaning policies that specifically deny coverage.
  2. By writing terms of the benefit so that no patient could possibly meet the requirements. For example, an insurer may not cover surgery if you have "an eating disorder." But if you weigh 400 lbs., how can you prove you don't have an eating disorder?
  3. By "punitive reimbursement," or, "You'll be sorry you made this claim." Hutcher has seen patients get pre-authorization (which can take several months), get the surgery, and then be required to receive lifetime follow-up, only to receive $900 total from their insurer.

Hutcher compares submitting a claim for bariatric surgery to playing roulette: "And in roulette, you know the house always wins," he says.

So why do health insurers seem to fail to see the cost-effectiveness in paying for surgery versus paying for years and years of treating related conditions? Hutcher's theory, honed from decades as a practicing surgeon, is greed--with a big dose of discrimination that "fat people don't deserve help."

"Health insurance is the only industry I know of where they consider doing what they are in business to do a loss," says Hutcher.

Other strategies for getting coverage

1. If your HMO plan doesn’t cover obesity surgery, change to a PPO plan at open enrollment if the PPO plan covers it.

2. Change to your spouse’s plan if it provides coverage.

3. Get a job with Microsoft. This is meant only partially tongue-in-cheek. Certain large employers cover weight-loss surgery as a commitment to employee health. According to ASMBS, these employers also offer coverage for weight-loss surgery: Intel, Toyota, FedEx Freight, and Harrah’s and Caesar’s Palace.

4. Consider paying out-of-pocket and ask your surgeon’s office about payment plans.

If you’re denied

The Professional Appealer

Walter Lindstrom is one of the best-known advocates in the country for folks seeking to overturn denials for weight-loss surgery. His California law practice (at ObesityLaw.com) evaluates potential appeals on a case-by-case basis by examining your insurance contract and medical records and then preparing a comprehensive written appeal that addresses all the possible reasons to approve the surgery. His office can also represent you at grievance and appeal hearings and prepare you for those hearings. 

If your plan doesn’t exclude coverage and you’re denied, appeal it. You will probably need to provide further documentation of your need for the surgery as medically necessary.

All health insurance plans should have a clear appeals process. Find out what it is and follow directions. You may only have a limited time from the date you were denied or had the procedure to get an appeal under way, possibly only 60 days. Depending on your plan's procedure, you might have to start with a phone complaint, and then move to a written appeal.

Hutcher advises individuals to call their insurer every day: “Be the squeaky wheel."

Ask for your surgeon’s assistance in putting together solid documentation. Some bariatric surgeons even have "appeals experts" on staff that have experience in getting claims paid after denial.

Keep meticulous records of your contact with the insurer and your appeal. There are two methods of appeal: internal and external. The internal appeal is to the insurer itself. An external appeal is to your state department of insurance or other governing body.

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