Think I am a good candidate for gastric bypass surgery What do I need to do to obtain insurance coverage for this procedure

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Unfortunately, it is not enough for you to think you will be a good candidate for surgery: you must also meet the National Institutes of Health guidelines for surgical eligibility. These guidelines state that candidates for obesity surgery must have:

1. A BMI of 40 or more, or in some cases a BMI of 35 or more in association with one or more major obesity-related medical or physical problems.

2. Failed all previous attempts at weight reduction by conventional means (diet, exercise, counseling, and weight loss medications).

3. No history of alcohol or substance abuse.

4. Realistic expectations of surgical outcome.

If you meet these guidelines, the next step is a visit to your primary care doctor to discuss surgery. If you have the type of insurance that requires a referral, you will need your primary care doctor to refer you to a surgeon. Your doctor should also write a letter of support on your behalf to your insurance company. If you have a long-standing relation ship with your primary care doctor, he or she will know about your weight loss attempts and will be treating you for any of your obesity-related illnesses or conditions (elevated cholesterol and triglycerides, gallstones, pancreatitis, abdominal hernia, fatty liver, diabetes or prediabetes, polycystic ovary syndrome, high blood pressure, heart disease, pulmonary hypertension, stroke, blood clots in the legs and lungs, sleep apnea, arthritis, gout, lower back pain, infertility, urinary incontinence, or cataracts).

If you do not have a long-term relationship with your doctor you should bring detailed notes to give her or him. These should include information on specific diets you have been on, when you were on the diet, and how successful you were. If you did lose weight during any of your weight loss attempts, you should supply your doctor with information on how long you were able to maintain it. Your primary care doctor should be aware of your obesity-related conditions, but if you have seen specialists for various problems, he or she might not have all the details of treatments you have received. If you want your procedure to be approved quickly, I suggest you draft a sample letter for your physician. (See Appendix B for an example of a sample letter.)

It is important to remember that many physicians have pretty healthy egos. You know your doctor (I don't). If you think your doctor would be insulted by you giving him or her a sample letter, think of a different way to phrase it. You might explain that you have researched the requirements of your particular insurance company and know that in order to avoid immediate claim rejection, certain things need to be included in a letter of support. Most physicians have had enough negative experiences with rejected claims that they will be happy that you have researched the claims process of your particular insurance company and that their time is less likely to be wasted. Physicians are also very busy — if you have drafted a good letter it is very likely that your doctor will dictate it nearly verbatim.

While a letter from your primary care doctor is helpful, the most important thing he or she can do for you is refer you to a good surgeon. It is important for you to be aware of the surgeons in your area who perform bariatric surgery. Since bariatric surgery has only recently become commonplace, your doctor may not know who performs this type of surgery in your community. If your doctor refuses to refer you and you know you qualify (see the NIH criteria above), then you need to find a new primary care physician.

If you have to go this route, make sure that the new doctor you select has at least referred a few patients for this procedure. You can get this information from various sources. One way to find a doctor likely to refer you is to call the office of the surgeon you hope to have do your procedure and ask which local doctors refer to him or her. You might also attend a support group or informational seminar and ask the patients present who their doctors are. Once you have a primary doctor in mind call the office and ask if he or she is accepting new patients. If the answer is yes, schedule an appointment.

Hopefully things will go smoothly for you and your current doctor will immediately refer you to a surgeon, but if this doesn't happen don't give up — find a new doctor who will make the referral.

Once referred, your surgeon's letter is generally the most important piece of information used by your insurance company. It is important to supply your surgeon with the same information you supplied to your primary care physician.

Your surgeon and his or her office staff will most likely be very experienced with writing the detailed letters of medical necessity. Often you will be asked to complete a formal questionnaire. These questionnaires usually include questions regarding your dieting attempts and your obesity-related conditions. Sometimes they include questions regarding the social and economic consequences you may have experienced related to your weight. All of this information will be used in your letter of medical necessity, so be honest and complete.

No one is more invested than you in obtaining insurance approval. And ultimately insurance coverage is your responsibility, so be proactive. Once you know your surgeon has submitted all the necessary paperwork to your insurance company, wait one to two weeks, then call the insurance company to check on the status of your case. Sometimes companies find trite problems with the application that hold up the process. One of my patients was unnecessarily delayed because the insurance company demanded additional proof that he had worked on a diet for a full year prior to seeking approval for coverage for weight loss surgery. Luckily I had clear documentation in his chart and was able to provide this information.

Bariatric surgery is becoming routine and is generally highly successful. As a result, more insurance companies are covering it. Nonetheless, many companies still make it painful. Some will deny coverage for any weight loss surgery, and they count on many people failing to appeal the ruling. If you are denied, don't give up — appeal the decision. Appendix C is a sample appeal letter. Obviously you will need to tailor it to your own situation, but this gives you an idea of what to include. You may also consider hiring a lawyer to handle the appeal for you.

I had one patient who successfully pitted one insurance company against another. My patient was covered under her own insurance plan and under her husband's plan as well. When her company refused coverage, her husband called his company and was told that coverage would be provided. His insurance company then told him that it would sue his wife's company for coverage. Miraculously his wife's company changed its ruling and the procedure was covered.

Most people are not in the lucky situation of having coverage with two insurance companies. If you are denied coverage, take a deep breath and get ready to fight. If you really do fit the NIH eligibility criteria, you should ultimately be successful.

As a way to boost your chances of immediate approval by your insurance company, I advise asking some of your other physicians to also write a letter of support to your insurance company. This might include your pulmonary doctor (if you have any obesity-related lung problems such as sleep apnea); your endocrinologist (if you have diabetes or poly-cystic ovary syndrome); your obstetrician-gynecologist (if you have obesity-related infertility or menstrual problems); your cardiologist (if you have obesity-related heart problems including an enlarged heart, high blood pressure, high cholesterol, a history of heart disease). The more support letters you have, the harder it is for your insurance company to deny you coverage.

If you find that your insurance policy specifically states that it does not cover treatment for weight loss and obesity, read between the lines. This usually means you are not covered for obesity medications or dietary counseling for the treatment of obesity. Weight loss surgery is a treatment for morbid obesity and is in a category of its own. It is important that you are aware of this distinction because many insurance companies will not point this exclusion out and hope you will go away.

Finally, although it may mean you have to wait a bit to qualify for gastric bypass surgery, you may need to change insurance companies. I have had a few patients who have done this in order to get coverage. Often employers only allow employees to change insurance plans (assuming they offer more than one option) once a year. You might need to discuss your situation with the human resources department at work. If you are lucky enough to have two or three options for insurance through your employer you will probably be able to find one company that will cover your procedure.

Another alternative, if you are married and your spouse could provide you with coverage, is to determine if making the switch would provide coverage for weight loss surgery. Still another (although more drastic) choice is to change jobs — but only do this if you know the new job will provide you with coverage for gastric bypass. If you have to go this route, once again you may be delayed as you accrue sick leave.

The last and least desirable option is the self-pay option. You may well have enough to cover the cost of an uncomplicated gastric bypass surgery. However you might not have an uncomplicated procedure. You might have complications that extend your time in the hospital or require a second trip to the operating room. In such a case the cost can really skyrocket.

Being forced to delay your surgery for insurance reasons may seem very frustrating at the moment, but try hard to remain upbeat. In the big scheme of things the timing of your surgery is not nearly as important as having it in the first place.

Melanie remembers being overweight as far back as kindergarten. Although a trained nurse who knew about nutrition and the importance of a well-balanced diet, her own life was a constant struggle to lose weight. She participated in medically supervised diets—from high-fiber to modified fasts—as well as trying every new fad diet on the market, but all without lasting success. At her peak she weighed 310 pounds, and she never saw below 200.

Melanie is smart, articulate, and hardworking, but she couldn't help but notice that despite these attributes, people treated her differently because of her weight. It was obvious to her that obesity was a handicap. "People immediately judge you—they think you are not ambitious, not hardworking."

After talking to her cousin, who knew someone who lost 100 pounds in six months due to gastric bypass surgery, Melanie wanted to consider it but assumed she could never afford the procedure. After researching the program and talking more with her cousin Melanie discovered that the procedure would be covered under her insurance plan. Melanie figured her BMI at 52—solidly in the range required for the surgery. She counted her blessings that she hadn't yet had any complications related to her weight, but at nearly forty, she knew that statistically it wouldn't be long before problems arose.

After waiting on an almost yearlong waiting list for the surgery, Melanie's day came. She shed 120 pounds. As can happen to many people, over the course of the next year she gained about 10 pounds back. She is working hard at losing them again. Melanie makes sure she walks thirty to forty minutes a day and tries to avoid snacking between meals, and is now working as the program director of Catholic Medical Center's Obesity Treatment Center in Manchester, New Hampshire, inspiring and supporting patients and physicians.

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CHAPTER TWO

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