“How Can Insurance Benefits For Bariatric Surgery Be Obtained After A Denial?” is taken from Medical Law Perspectives’ January 2019 Special Report entitled “Heavy Liabilities: Obesity, Weight Control, and Treatment Risks” and is reprinted with permission from Wordsworth Law Publications.
“Bariatric surgery is well-established as the standard of care treatment for appropriately selected patients affected by severe obesity when non-surgical modalities have not resulted in permanent weight loss. When a surgeon, usually in consultation with a team of other integrated health care professionals, determines bariatric surgery is medically necessary, the usual practice is to request authorization from the patient’s insurer on a pre-service basis. Unfortunately, these requests are frequently denied improperly, at least from our perspective as patient advocates, and are often devastating to patients.
Care must be taken to avoid a knee-jerk response before evaluating what happened and why so an appropriate appeal can be submitted. While it is reasonable to hope treatment will be approved as the health plan’s response to its member’s internal appeal, the best chance of getting a denial overturned may be during the independent, external review that can be requested if the plan upholds its denial.
The reasons payers most often cite as grounds for denying bariatric surgery are: (1) a lack of medical necessity based on the payer’s medical criteria; and (2) bariatric surgery is excluded as a benefit. While seemingly simple, appealing these denials will fail unless the true underlying reasons are addressed. Experienced advocates in the world of bariatric surgery understand that many payers rely on clinical criteria that is outdated, reflecting coverage prerequisites, which have been rejected by bariatric specialists. Examples of arbitrary, clinically unsupportable medical criteria cited by payers include:
Participation in so-called “mandatory” non-surgical weight loss programs even though the American Society for Metabolic and Bariatric Surgery (ASMBS) has demonstrated these programs harm patients by delaying treatment;
Arbitrary requirements concerning how severe co-morbid diseases such as type 2 diabetes, obstructive sleep apnea, hypertension, lipid disorders, etc. must be in order to justify surgery. Payer criteria often requires a patient almost be too sick to be operated on rather than using standards developed by bariatric experts; and
Arbitrary requirements that ignore the positive impact bariatric surgery has on some diseases to artificially restrict coverage.
Payers demonstrate a particular hostility to patients seeking additional surgical intervention after the failure of a prior operation. Here are just a couple of examples of how aggressively payers try to limit second procedures:
Medical policies that are not part of the member’s contract that assert coverage is limited to “one surgery per lifetime” regardless of whether the present insurer covered the original procedure;
Agreements to cover the reversal of a procedure, such as removing a failed gastric band, but denying a revision to a new intervention even when no other restrictions on revisions exist for orthopedics or comparable limits to a single type of cancer intervention; and
Placing blame on the patient for his or her supposed failure to comply with a treatment plan as a rationale for denying a revision. This is tantamount to saying “You had your one chance and you blew it!” No other surgical treatments covered under these health plans similarly limit physicians to a single opportunity to treat a disease.
The introduction of new technology in the form of FDA-approved medical devices used in the surgical treatment of severe obesity will usually lead to a payer claiming use of the technology, whatever it might be, is “experimental” or “investigational.” They rely upon these labels even when the plan Definitions for these terms are found inapplicable and the device or technology is well-established.
Contract exclusions form the other major category of barrier faced by bariatric patients. Careful analysis of the language must be done to make sure the plan is not claiming an exclusion applies when in fact the actual denial is based on medical necessity. Experienced advocates have to grasp a great deal of clinical nuance to establish situations when medical judgment is required – thus making the case a medical necessity denial as opposed to a contract exclusion. The key reason for that is because exclusions are not subject to independent review; medical necessity and experimental/investigational denials have that as the next available option to challenge a denial.
The independent review organization (IRO) process is supervised by an agency with appropriate accreditation, which identifies an impartial medical expert in the same discipline as the requesting physician – in this case, a bariatric surgeon. They review the documentation and determine whether or not the surgery should be approved. Their importance rests with the fact they are not bound by the payer’s medical criteria. For example, a health plan’s medical policy might require a bariatric patient complete a six-month medically supervised weight loss program to establish medical necessary. The IRO reviewer is free to disregard that criteria knowing that there is no evidence-based standard that provides a benefit is gained by delaying care. Because medical criteria used by payers is so often outdated, the IRO is often the most powerful tool patients have to combat wrongful denials predicated on arbitrary and outdated medical criteria.
All too often bariatric surgery providers try to avoid payer denials at all costs – even if the payer’s criteria has no clinical support. There are dangers to playing the payer’s game because bariatric surgery, unlike accepted treatments for any other disease, isn’t always going to be part of a member’s coverage. Providers and patients alike must act quickly and decisively to seek approval by submitting all available supporting medical documentation whenever possible.
But, it is more important to not delay submitting the preauthorization request to the health plan, even if their arbitrary criteria isn’t met because a patient’s existing coverage for bariatric surgery insurance cannot be taken for granted. It is coverage that may disappear while a patient tries to jump through just one more hoop. Among the most tragic mistakes we see are patients who are forced to meet arbitrary medical policies – taking months and months to do so, only to have bariatric surgery excluded when their new plan is issued.”
CALL US at 1-877-992-7732 to learn how we can help you (or your bariatric surgery patient) successfully appeal an insurance company’s denial beforejumping through unwanted hoops!
This made my life. Literally. I cannot begin to thank you enough for your expert help in having this over turned for me. I know without your help, it wouldnt have been possible. My surgeon has me scheduled for surgery on Feb 6. I will be sure to stay in touch and let you know how it all goes. I have a lot of hope that I will be able to come off of my insulin pump and have better control with just a few injections. I truly believe this is possible for me, and that my quality of life will be so much better. The work you have done is going to change so much for me. I plan, in turn, to make a difference for many others. Its a pretty great ripple effect, isnt it?
I hired them for my appeal. They were great and I was approved a week after submission and my case was not an easy win. I was a revision case and Walter’s appeal letter brought tears to my eyes.
Walter and Kelley,
1 year ago today I had surgery with Dr. Alok Gandhi at Rochester general hospital. I am happy to report that I have lost 120 lbs., off all of my medicine and cpap machine. I take vitamin supplements but everything else is gone. I just wanted to thank you again for your help with CIGNA and wish you both a great day and a very heartfelt “Thank You”.
Mrs. Lindstrom, Thank you for the great news.I will call my surgeon’s office to work out a schedule. I am grateful that they referred me to your office and I will recommend you to anyone who needs assistance.I believe that this result was achieved only through the advocacy of your firm. Thank you very much for all of your effort.
Wishing you and Walter a GREAT 2015 also. You both gave me the tool I needed to get my life back – without the both of you (and your AMAZING team) working on my case I cannot say that I would be where I am today. I APPRECIATE all you did and continue to do for people like me. I continue to spread the word about your advocacy group and all you can help other accomplish if they only make that first call or send that first email like I did. I hope others I have talked to have taken advantage of the help and guidance you can provide. I will sing your praises to anyone who will listen – especially if they have a denial for surgery.
Oh my goodness!!!! Kelley – I can’t say thank you enough!!!! Thank you, thank you, thank you!!!! This is the BEST news ever. I am SO HAPPY! Thank you! Please tell me where/how I can leave you a review. Both you and Mr. Lindstrom went so above and beyond my highest hopes. I am so incredibly thankful. You guys are the best! Calling now to schedule the surgery!!!
I am absolutely over the moon excited right now. I finished my 6 months supervised diet/nutrition with my surgeon’s office back in April, but I was denied when it was submitted to insurance, despite having a BMI of 42 and GERD (they denied it and said GERD wasn’t one of their approved co-morbidities, and my insurance plan requires a co-morbidity regardless of BMI). I immediately contacted Lindstrom Obesity Advocacy and began the appeals process with them. Within a month of them sending in my (wonderfully written) appeal letter, I just received a call to let me know that United has approved me for surgery and has provided their office with the approval and authorization number. . . . I am beyond excited! This is actually happening!!
I just called my doctor’s office and the scheduler was absolutely amazed the denial got overturned! She said she has done tons of appeals for patients and it doesn’t ever usually work out this way. I can’t speak highly enough of Kelley and the Lindstrom group.
I had to go to external review but I’m now APPROVED for revision from Band to RNY!!!! I can’t say enough positive things about Kelley & Walter at Lindstrom Obesity Advocacy. If you find yourself stuck with denials from insurance companies, I highly recommend them!
I just wanted to update you and let you know how much we appreciated your help in getting us this approval. My wife had the procedure done in October and has been doing great. Already she has lost weight and her sugar counts are stable and doing fine. The Doctor has taken her off Insulin and High Blood Pressure medicine as a result. She feels real good on the progress she made so far. Once again, thanks for all your help.