Insurance Assistance: DS Only, and a Primer for All

[DianaCox]

After years of spending many many hours per month helping (mostly) DSers who have been denied insurance coverage for bariatric surgery, Larra and I have decided to limit our help to people seeking a virgin or revision DS.

Some of this is time-based – we’re busy with our own lives – but some of it, frankly, is that we cannot in good conscience promote bariatric surgeries with substantial failure rates both for sustained weight loss and for resolution of important comorbidities.

So, to help EVERYONE have fewer problems with getting insurance approval or taking some self-help steps, here is a guide for how to do your own insurance appeal, starting with the work you should do before you and your surgeon ever submit for preauthorization.

BEFORE SUBMITTING A REQUEST FOR PREAUTHORIZATION

1. Obtain a copy of your Evidence of Coverage (EoC – your insurance contract) and READ IT.

• It is usually around 100 pages long – it is NOT the much shorter Summary of Benefits insurers commonly give everyone.
  • Also, find the bariatric policy for YOUR plan – it may be in the EoC, or it may be in a separate location (often online on your insurance plan’s Medical Policy page)

2. Document every interaction with your doctors and insurance company – name, title, date, time, phone number,and notes about the conversation. You can't know in advance what documentation you will need in the future.

3. KNOW THE REQUIREMENTS OF YOUR PLAN: if your surgeon's staff submits your request for preauthorization before all your requirements are completed, you will be denied. There are MANY different policies, some with requirements that take months to fulfill, so learn YOUR requirements, in detail, and make sure you do them exactly as specified in your policy.

• Most insurance companies do not cover procedures that are either experimental or outdated, such as
  • jejunoileal bypass (JIB)
  • vertical banded gastroplasty (VBG)
  • biliopancreatic diversion without duodenal switch (BPD)
  • "stomach stapling"
  • adjustable bands other than lap band
  • mini-gastric bypass
  • any of the stoma repair (for gastric bypass) procedures like Stomaphyx, transoral ROSE, etc.
  • single anastomosis (misleadingly named) pseudo DS procedures like SADI/LoopDS/SIPS
  • gastric balloon
  • gastric pacer

• For BMI between 35-40, the requirement is usually a severe comorbidity, such as type 2 diabetes, uncontrolled hypertension, sleep apnea, disabling osteoarthritis – it is very difficult to get around this requirement.
• Sometimes there are unreasonable limitations on the DS, requiring very high BMIs – these can sometimes be overcome, as there is no medical evidence supporting them.
  • There is published scientific evidence, as well as the position statement of the ASMBS.
• For revision procedures, requirements are often different and more difficult to meet than for a primary bariatric procedure.
  • Some policies do not cover any revisions unless there is a proven technical problem with your prior operation (lap band slippage, for example).
  • Some policies include a "one bariatric surgery per lifetime" clause, regardless of who paid for the first surgery.
  • Those that do cover revisions usually demand "proof" of compliance with the post-op requirements of the prior surgery.
• Work CLOSELY with your doctor to TELL HIM/HER what your plan’s requirements are, and how to meet them, and make sure the doctor carefully documents every appointment and discussion you have, so it can be submitted with the surgeon’s request for preauthorization.
• Make sure that your surgeon understands the requirements of your policy as they pertain to what is documented in his/her notes.

 

[DianaCox]

IF YOU ARE DENIED:
1. Get the denial in writing. This is how you know the justifications for the denial and can work to refute them.

• Are they overlooking something you submitted?
• Did you forget/fail to meet a requirement?
• Did they find something negative in your medical records (eating disorder, psych issues, non-compliance with a previous bariatric surgery or other treatment plan)?
• Are they making a factually unsupportable medical assertion/opinion (e.g., that your BMI is too low)?

2. CAREFULLY read your appeal rights in the denial letter:

• There are deadlines for appealing – make sure you note them on your calendar!
• You need to understand the process for exhausting your internal appeals

3. Know whether your plan is self-funded or fully funded (you may need to ask your HR department)

• Fully funded plans are usually externally appealed to the state insurance agency, and fall under the purview of the state insurance laws of the state where the insurer's headquarters is located.
• Self-funded plans are usually very large companies/organizations (like state employees, large hospital chains, high tech companies) in which the employer absorbs the risk and reduces costs by only buying the administrative part of an insurance plan, the insurance company administers the plan but the employer pays the actual medical bills.
  • These plans usually only have to meet the minimal Federal ERISA (https://www.dol.gov/general/topic/health-plans/erisa) requirements, and are usually appealed either to an external medical review agency of the employer’s choice, or to an internal medical review board at the company.
  • They CAN arbitrarily overrule the insurance plan’s written policies; but rarely do since the employer will then have to pay the bills.

4. Understand that your surgeon and his/her staff are probably not going to be of much if any help on your appeal, and YOU must take control of the appeal process.

5. You will need to submit additional documentation and facts to overcome the basis for denial, either to prove something they overlooked or refute something they are asserting.

• This is going to require at least two letters:
  • A supplementary letter from your surgeon supporting your suitability for the selected surgery, usually called a letter of medical necessity (LOMN)
    • You may have to draft the letter FOR the surgeon, detailing the information that you want him to put in his letter that points out factual corrections, additional information, etc. – YOUR SURGEON IS NOT NOT NOT going to put in the time to do this correctly, and YOU will have a much stronger LOMN if you write the letter for him/her, and ask to have it put on the surgeon’s letterhead and signed.
  • A letter from you, establishing that you have met the plan’s requirements for surgery, or that the plan’s requirements are not within the standard of care guidelines.
  • You may also need a supplemental letter from allied professionals proving that you are knowledgeable about your procedure and are currently deemed to be able to be compliant with the requirements of living with the procedure (even if you were not in the past)

6. Submit your appeal in a method that requires a receipt.

7. Continue all levels of internal appeals until they are exhausted.

• Once you have exhausted your internal appeals, then you will send the whole package, with a summary cover letter, for external or independent medical review (IMR or EMR).
• There will likely be at least a form that you have to fill out to go with it.

A few more things:

• This procedure can take 3-8 months – time limits are often ignored by the insurance company and there is almost no recourse when they do.
• Once you have received a written denial, your appeal rights have vested.
• If you have the means, and want to proceed with surgery as self-pay, you can pay for surgery, keep the receipts, and continue appeals AFTER your surgery, but you must keep the time limits for filing the appeal in mind.
• And finally, please please please don’t get an inferior procedure because it’s quicker or cheaper!

THINK TWICE, CUT ONCE!

 

[k9ophile]

Thank you, ladies. You both have been a valuable asset to the DS community.

 

[Munchkin]

Thank you for writing this!

 

[DianaCox]

There is still something funky going on with the BF website - it took me dozens of tries to post the above, which I had to split into two posts, and it won't let me fix formatting or typos/errors - most importantly:
"Fully funded plans are usually externally appealed to the state insurance agency, and fall under the purview of the state insurance laws of the state where the [insurer's] employer's headquarters is located"

 

[Trilla]

This is tremendous information. I just received my denial and I will need to go over all of this thoroughly. thank you DianaCox for creating this for us.

 

[galaxygrrl]

This is awesome!

 

[Diana S.]

Larra and I have decided to limit our help to people seeking a virgin or revision DS... we cannot in good conscience promote bariatric surgeries with substantial failure rates both for sustained weight loss and for resolution of important comorbidities.

Wait, what?

Or am I reading that super-pants wrong..?

 

[hilary1617]

Wait, what?

Or am I reading that super-pants wrong..?

I read it to mean that they won't take on insurance battles for lapbands, RNY, SIPS/SADI/Loops, etc. - that they will strictly advocate for DS patients.

 

[DianaCox]

Yup.

 

[michelle vasey]

I am so grateful to both of you for your time and assistance. I am going forward with a self-pay surgery and will continue my appeals process for recompense. Again, thank you!!!

 

[Diana S.]

I’m going to blame my brain-fart there on a serious lack of caffeine

 

[candlebelle]

Hi Diana and Larra - thank you for this very detailed and helpful post! Are you still assisting folks that are seeking to overturn a denial for revision surgery from RNY to DS? I was scheduled for my revision to DS next Monday (June 27, 2022), but my insurance company just denied me last week. My surgeon had a peer to peer review, but the insurance company said they will only cover bariatric revision for a "technical failure" resulting from the original surgery. Needless to say, I am beyond devastated! My plan is a self funded plan, but my claims administrator is United Healthcare. We have an option to use Blue Cross as our claims administrator, but because it is a self funded policy, I assume switching would still yield the same result. I am going to appeal in writing with United Healthcare, but am hoping for some guidance or examples of appeal letters that I an use that might yield a positive result. I had RNY back in 1999 (HW 273, LW 143, but then developed a transfer addiction and got pregnant, so subsequently regained the weight over the years. I have been sober for 10 years, but I now weigh 294 and my surgeon's office was sure I would qualify because my BMI is 50, and I have sleep apnea and a hiatal hernia. I would love to hear any guidance you may have or resources you can point me to - thanks so much for your help!

IF YOU ARE DENIED:
1. Get the denial in writing. This is how you know the justifications for the denial and can work to refute them.

• Are they overlooking something you submitted?
• Did you forget/fail to meet a requirement?
• Did they find something negative in your medical records (eating disorder, psych issues, non-compliance with a previous bariatric surgery or other treatment plan)?
• Are they making a factually unsupportable medical assertion/opinion (e.g., that your BMI is too low)?

2. CAREFULLY read your appeal rights in the denial letter:

• There are deadlines for appealing – make sure you note them on your calendar!
• You need to understand the process for exhausting your internal appeals

3. Know whether your plan is self-funded or fully funded (you may need to ask your HR department)

• Fully funded plans are usually externally appealed to the state insurance agency, and fall under the purview of the state insurance laws of the state where the insurer's headquarters is located.
• Self-funded plans are usually very large companies/organizations (like state employees, large hospital chains, high tech companies) in which the employer absorbs the risk and reduces costs by only buying the administrative part of an insurance plan, the insurance company administers the plan but the employer pays the actual medical bills.
  • These plans usually only have to meet the minimal Federal ERISA (https://www.dol.gov/general/topic/health-plans/erisa) requirements, and are usually appealed either to an external medical review agency of the employer’s choice, or to an internal medical review board at the company.
  • They CAN arbitrarily overrule the insurance plan’s written policies; but rarely do since the employer will then have to pay the bills.

4. Understand that your surgeon and his/her staff are probably not going to be of much if any help on your appeal, and YOU must take control of the appeal process.

5. You will need to submit additional documentation and facts to overcome the basis for denial, either to prove something they overlooked or refute something they are asserting.

• This is going to require at least two letters:
  • A supplementary letter from your surgeon supporting your suitability for the selected surgery, usually called a letter of medical necessity (LOMN)
    • You may have to draft the letter FOR the surgeon, detailing the information that you want him to put in his letter that points out factual corrections, additional information, etc. – YOUR SURGEON IS NOT NOT NOT going to put in the time to do this correctly, and YOU will have a much stronger LOMN if you write the letter for him/her, and ask to have it put on the surgeon’s letterhead and signed.
  • A letter from you, establishing that you have met the plan’s requirements for surgery, or that the plan’s requirements are not within the standard of care guidelines.
  • You may also need a supplemental letter from allied professionals proving that you are knowledgeable about your procedure and are currently deemed to be able to be compliant with the requirements of living with the procedure (even if you were not in the past)

6. Submit your appeal in a method that requires a receipt.

7. Continue all levels of internal appeals until they are exhausted.

• Once you have exhausted your internal appeals, then you will send the whole package, with a summary cover letter, for external or independent medical review (IMR or EMR).
• There will likely be at least a form that you have to fill out to go with it.

A few more things:

• This procedure can take 3-8 months – time limits are often ignored by the insurance company and there is almost no recourse when they do.
• Once you have received a written denial, your appeal rights have vested.
• If you have the means, and want to proceed with surgery as self-pay, you can pay for surgery, keep the receipts, and continue appeals AFTER your surgery, but you must keep the time limits for filing the appeal in mind.
• And finally, please please please don’t get an inferior procedure because it’s quicker or cheaper!

THINK TWICE, CUT ONCE!