“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 Experienced advocates in the world of bariatric surgery understand that many payers rely on clinical criteria that is outdated, reflecting coverage prerequisites, which have been rejected by bariatric specialists.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!
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.
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!!
Thank you so very much for this wonderful letter of request. I honestly regret not contacting you when I was initially denied. I am just flabbergasted at the detail and the evidence based references provided. WOW!!! I deeply regret not knowing you existed. You really take the WORD advocacy to a whole new MEANING. Words cannot describe how satisfied I am to see such documentation and how thankful I am for your help. Thank you!
OMG! I was NOT expecting this! I tried to call you when I received your message, but I think your office was already closed for the day. I will call back tomorrow just to say THANKS in person! Looks like Christmas came early! I will contact the doctor’s office tomorrow to schedule the surgery as quickly as possible…Words cannot express how thankful I am for your help! You have been such a pleasure to work with! I will make sure my surgeon and his office staff know how helpful you have been so they can be sure to recommend you to others that might be struggling with the same problem.
You are the best Thanks again for everything you did. I know for sure I never could have accomplished this on my own!
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.
Dear Walter and Kelley: Today is the 1-year anniversary of my lap-band surgery. To date, I have lost 67 pounds and I am in the best shape of my life – I don’t remember a time that I weighed as little as I do now, not even in high school. The time you spent appealing my case was invaluable and absolutely life-changing for me, and I just want to let you know how very much I appreciate all the work you put into it on my behalf. I am thankful beyond words! God bless you!
Thank you so much Kelley (and Walter!). I so appreciate all you have done for me!!!
I’m so excited to finally be able to move on!
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.
I was turned down by my insurance company because they said I was not fat enough for long enough. I hired the Lindstrom group and they were great. I was approved a week after they submitted my appeal….it was so worth it. They are the nicest people. I do not regret hiring them. I just wish I did it sooner.
After my initial denial by Cigna I hired Lindstrom Obesity Advocacy to handle my appeals and am happy to say that my denials were overturned on independent review. Kelley was wonderful, always available to me and always on top of the appeals at every turn. She kept me informed of any progress as soon as it developed. She really seems to care about her clients. I highly recommend using them. My first denial was in June and the denials were overturned in August on independent review. My surgeon’s office commented on how fast the process was compared to the experience of others in their office. . . . It was the best money I ever spent and I am over the moon that this worked out for me. My recommendation is don’t wait to contact them. I contacted them immediately after I got my first denial and they handled the rest. So that’s my two cents!