MUSC Bariatric Surgery Program

bariatric surgery PROGRAM

Insurance Benefit Guidelines

Many insurance companies have their own specific benefit guidelines, describing whether weight loss surgery treatment for morbid obesity will or will not be covered. If it is a covered benefit, they have specific requirements that must be met before they will authorize benefits for the treatment. The process can be long and difficult requiring much effort on the part of the patient and the surgeon’s office. 

The following is a basic list of what insurance companies are requiring in order to determine if bariatric treatment for morbid obesity is a covered benefit.

**PLEASE NOTE THAT WE WILL NOT BEGIN THE PRE-CERTIFICATION PROCESS UNTIL YOU HAVE PROVIDED OUR OFFICE WITH ALL REQUIRED INFORMATION:

  • Documentation of Dieting. Many insurance companies require documentation of a medically supervised weight loss attempt. This can be in the form of medical records from your primary care provider or receipts for weight loss programs. Some insurance companies have gone as far as requiring a 6-month daily record of eating habits.
  • Documenting Exercise Attempts. Many insurance companies are asking for documentation of exercise attempts. This can be in the form of attendance records at exercise programs, receipts for gym membership and records from rehab appointments.
  • Psychological evaluation. Most insurance companies require a psychological evaluation. This can be in the form of a psychological screen to test your state of mind and ability to cope with surgery and the change in lifestyle that is necessary afterward.
  • Medical records. Medical records are required, and must be submitted with all other documentation prior to the insurance company making a determination.
  • Letter of Medical Necessity. This is a letter usually written by your surgeon that outlines your medical, diet and exercise history and your current state of health. It is the summary of all your information that makes the case for why surgical treatment for your morbid obesity is medically necessary. This letter is usually submitted with all your other documentation.
  • Predetermination. Once all your records are gathered and sent into the insurance company with the letter of medical necessity, the insurance company goes through a review process to determine if they will approve this benefit for you. At this point they may either ask for more documentation, approve this benefit for you or deny this benefit to you. If you are denied, most insurances have up to 3 appeals that they allow you to make. It is important not to waste these appeals and make sure all documentation is complete prior to filing an appeal. It is also important not to give up during the appeals process as many initial denial decisions are overturned in later appeals.
  • Pre-certification. If your benefits for treatment have been approved, a final process of pre-certification through the insurance company is made, in which the scheduling of your operation, the surgeon you will be working with and the facility at which you will undergo the procedure are determined. Pre-certification generally must take place within 90 days of predetermination to be valid.
 
 
 

© Medical University of South Carolina | 171 Ashley Avenue, Charleston, SC 29425