In case your health insurance claim got denied for Bariatric Surgery, you may want to appeal against the decision. But how do you do that?

These six steps will hopefully help you:

1. Get a written denial letter from your insurer

First, obtain a denial letter that contains all the basic information. Apart from mentioning the name, the credentials, and the title of the person who denied your claim, a denial letter needs to include the clinical rationale and the medical criteria supporting the denial. A denial letter must also contain instructions to appeal to the decision. In addition to that, contact information, instructions for correctly filing external review and for obtaining further assistance need to be given.

In case the denial latter given to you lacks any of the above mentioned elements, contact your insurer and get the additional information.

2. Understand the guidelines

Before going ahead with your appeal, you must take the time to understand the appeal guidelines of your provider. Different insurance companies have different guidelines, and to maximize your chance at winning, following guidelines is important.

3. Get support from those who are willing to help

Most reputed medical centers have insurance coordinators who know a lot about the appeal process. Contact your Bariatric medical center to find out if someone can help you. In case a bariatric coordinator cannot find success, you may even request your bariatric surgeon to call someone in the insurance company who has high authority. In addition to that, your company’s HR center may be of great help, too!

4. Prepare an effective appeal letter

Never write a weak unprofessional letter. Put effort to prepare an appeal letter that looks highly professional and standard.

5. Keep track of your correspondences

In addition to noting the times and the dates of each of the correspondences, you should note the medium of correspondences, too. That is, whether a discussion took place over phone, email, fax or something else. You must also keep track of all the titles and names of the different representatives you speak with. Other than that, save a summary of whatever is talked about during any correspondence. Further, make sure that you send your letters using certified mail carriers only. That way, you can have proof regarding when you sent those letters.

6. Make sure that you follow up

All your efforts will be wasted if you fail to persist. Make sure that you do not stop your journey until you get a final official response from your insurance provider.

If your insurance provider does not budge even after you follow the above steps, you may want to go a step further and involve lawyers and other influential third parties.

In case your health insurance claim just got denied, you are probably wondering what step to take next.

One thing you can do is make an appeal. But for that, you need to know the procedure first. So how do you make an appeal exactly?

First of all, even before you touch your pen or keyboard, it is important to contact your doctor’s office and ask for all the important information that you may need to include in your letter. You can also get helpful suggestions from knowledgeable staff there. In addition to that, the office may have a great letter template to help you complete the appeal process easily and quickly.

Secondly, you need to obtain some basic information from your insurer in a standard denial letter.

Once both of the above steps are completed, it is time to write the actual letter.

In order to be effective, your Bariatric Surgery appeal letter should contain the following six elements at the very least:

1. Basic policy information

It goes without saying that your letter must contain your name in full at the beginning. The letter must also contain policy information and treatment information. You can find such information easily if you examine your insurance company’s Explanation of Benefits document. Writing your policy number, treatment dates, description of treatments, and total doctor fees should be enough.

2. The reason for denial

Why was your claim denied in the first place? State that reason in your letter. Make it easy for your insurance provider to track your case. Do not assume that your insurance company will just know the reason.

3. Your intention

Make it clear that the reason for writing your letter is that you intend to make an appeal.

4. Important document copies

Send all the records that your insurer used at the time of denying your claim. Also, include records that may be required to approve your claim if the company chooses to do so. In addition to that, do not forget to enclose copies of medical opinions provided by your insurer regarding the denial.

5. Claim re-review request

Request your insurer to review your claim once again in accordance with any newly provided data. This one applies only if you provide additional documents or information responding to the denial.

6. Your contact information

Never end a letter abruptly without giving your contact details. Where would you like to be contacted for further correspondence by your insurance company? Write down that address correctly at the end of the letter.

If all else fails, you can still get medical financing. Read more about bariatric financing here.

Bariatric surgery is an expensive procedure. So in case you do not have a medical insurance, or your insurer refuses to cover your surgery costs, you may feel discouraged. You may even think about retreating or postponing your surgery.

However, there is no reason to panic. Because, even without the support of your insurance provider, it is totally possible to get your surgery done without breaking your financial backbone!

Chat with our Bariatric Coordinator Online to find financing options!

Why take the leap?

We will talk about where to find financial help in a moment, but first let us see why undergoing bariatric surgery is a good idea even when money is tight:

Bariatric surgery assures cheaper future

Nearly all patients who undergo bariatric surgery report decline in their expenses after about 13 months of surgery. In fact, data suggests that obese people spend nearly 900 dollars more every month compared to those who had the surgery done.

Bariatric surgery lengthens life

Since a huge number of health problems disappear after bariatric surgery is done, quality of life improves by a large margin. And hence, a longer life is almost guaranteed!

Bariatric surgery improves professional life

Obese people are often discriminated against by peers and colleagues at work. It may sound harsh, but many obese people get lesser salaries than they deserve just because they are obese. So once bariatric surgery is out of the way, others are likely to treat a person in a nicer and more respectful way.

What kinds of financial help exist for bariatric surgery?

Now that you know why bariatric surgery is worth embracing, let us consider the ways in which you can finance the procedure:

Secured medical loans

Obtaining a secured loan from any reputed credit union or bank is a good idea in case you own a house that has about 10 to 20 percent of built up equity. However, keep in mind that this option requires collateral on your part. Also, since the process of obtaining a secured loan is a bit complex, most people prefer to obtain unsecured loan as long as the loan amount does not exceed $15,000.

Unsecured medical loans

If you have no intention of providing collateral, then getting an unsecured loan is your best bet. The problem in this case is that since there is no collateral involved, the interest rate is going to be higher than that of secured loans. Other than that, having a good credit score is crucial if your aim is to successfully receive an unsecured loan. For more details, you can contact brokers, lenders and credit card companies who provide unsecured loans in your area.

In those states of the US where bariatric procedure is regarded as an Essential Health Benefit, Obamacare makes it mandatory for insurance providers to ensure that bariatric surgery coverage is given under all small-group, family and individual plans under the Affordable Care Act.

In this article, we list the states that are covered, illustrate the limitations of the act, and tell you what to do if your state is not included.

States covered for bariatric surgery under Obamacare

Excluding a select few, nearly all states make it mandatory for all small-group, individual and family plans to provide bariatric benefits. Residents from Arizona, Delaware, California, Hawaii and Illinois can obtain bariatric surgery benefits. Those who live in Maine, Iowa, Michigan, Maryland or Massachusetts are also eligible. In addition to that, people from Nevada, New Jersey, New Hampshire and New Mexico can benefit from the act, too.

Other states that make bariatric surgery insurance benefits mandatory are North Carolina, New York, Oklahoma, North Dakota, Vermont, South Dakota, Rhode Island, West Virginia and Wyoming.

If your state is excluded

In the event that the above paragraph did not mention your state, it is likely that your insurer is not obligated to give you any bariatric surgery benefit. Even when you get your surgery done in some other state, you will still not be able to claim any benefits. The good news is that many organizations and authorities are working hard to change certain policies of the Affordable Care Act in order to make bariatric surgery mandatory within more states.

Is there any other catch?

Since the act treats bariatric surgery as an Essential Health Benefit, the initiative is of no use in case of larger groups. That is, if a group has more than 50 employees, then Essential Benefits are not going to apply. That means if you work in a company having over 50 employees, you will not be eligible for receiving bariatric insurance coverage.

What if you are unsure?

In case you are unsure whether your insurance provider gives you bariatric surgery benefits or not, you may want to contact a local bariatric surgeon. Without charging you anything, the surgeon’s office will get in touch with your insurer and obtain information on your behalf. After that, it is great if you find that the procedure is covered by your insurance provider! But at the same time, there is no reason to lose heart even if your insurance company informs that it does not cover the procedure. That is because you can still get secured and unsecured loans from various sources to cover the costs.

In the light of recent studies, it appears that obesity is not really curable by eating less. The researchers behind The Lancet Diabetes and Endocrinology argue that, for the most part, obesity proves itself as a disease that is chronic, having biological reasons which cannot be eliminated by exercise or diet.

Almost 80 to 95 percent of obese people who experience short-term good results after controlling diet end up being obese again when few months pass. One reason for that may be our body’s tendency to prompt us to consume foods rich in calories when we suddenly decrease our caloric intake.

The problem is, in case of obese people, the mentioned biological tendency actually encourages fat storage in order to protect a person’s maximum sustained weight. As a result, overriding this kind of defense does not seem to be possible for the majority of patients, if only lifestyle alterations are embraced.

Dr. Christopher Ochner, the lead author, expresses that obesity can often turn into something that is biologically defended, and hence, advising an obese person to eat less is somewhat like suggesting a bleeding person to avoid sharp risky objects. Note that Dr. Christopher is Pediatrics and Psychiatry Assistant Professor who works in the Icahn School of Medicine, New York.

The professor further states that most obese people are truly and significantly different biologically from their counterparts who have normal weight. In many cases, he argues, their biological changes may last indefinitely, which makes it nearly impossible for them to sustain long-term weight loss.

According to the authors, in order to sustain weight loss permanently, interfering with biological factors is necessary. The present biological interventions are not very capable, since those are limited to ways like surgeries, drugs, nerve blockage etc. that do not exactly provide permanent correction.

To date, only Roux-en-Y gastric bypass could show reversal of obesity-induced alternations upon hormones associated with appetite, and on how our brain responds to food. The authors argue that this may be one reason why the method of bariatric surgery seems to be the only viable treatment for eliminating obesity completely.

Dr. Christopher concludes that a huge number of clinicians do not really understand the reasons why obese people find it difficult to lose weight. According to him, obesity needs to be recognized for what it is – a chronic, and sometimes treatment-resistant, condition. He notes that without biological interventions, obesity may not be possible to eliminate by lifestyle modifications alone; and relying only on modifying behavior will only result in yearly deaths of millions of sufferers.

What do you think?  Share your opinion on this study.

A recent study that appeared in the Obesity journal pointed out that food addiction can be significantly lowered with the help of bariatric surgery. The results of the research showed that the surgery, which is primarily used to reduce weight, probably has the ability to decrease a large number of eating disorders associated with extreme obesity, as well.

Note that even though bariatric surgery has been widely accepted as one of the highly effective weight loss therapies for treating obesity, it is yet undetermined to what extent the surgery can influence food addiction.

So, a study undertaken by some researchers of the Atkins Center of Excellence and the Center of Human Nutrition of St. Louis’ Washington University School of Medicine attempted to tackle exactly that. They wanted to see if weight-loss-induced gastric banding, gastric bypass, or gastrectomy played role in food addiction remission. Another aim of the study was to understand eating behavior normalization patterns.

For conducting the study, 44 patients were picked, each suffering from obesity. Among them, 39 were women. The patients exhibited mean BMI of 48 ± 8. The researchers examined the patients before the surgery and after it. Among the subjects, 25 experienced gastric bypass, 8 exhibited sleeve gastrectomy, and 11 showed gastric banding.

Besides that, 14 or 32 percent of the 44 subjects showed food addiction before the surgery took place. Factors like race, age, education level, or income level did not affect that.

Reports showed that food addiction decreased surprisingly in 13 of the total 14 subjects, or in nearly 93 percent of cases, after the surgery was done. Once the surgery being over, new cases ceased to crop up. Food addiction prevalence reached 2 percent from 32 percent (p< 0.00001). In addition to that, all subjects started to experience lesser extent of median symptoms (p< 0.0001).

Both the groups showed reduction in food craving after the surgery, but the effect was more pronounce among the patients who had serious food addiction. When the surgery was over, even patients who craved food very frequently stopped craving food much. Another thing noticed was that the craving for starch did not decline a lot among the noted food addicted subjects (p=0.009) after the surgery, even though that did not apply in case of other foods.

The authors of the study concluded that, based on the data, it was evident that obesity does not really result in food addiction. However, food addiction certainly seems to be one of the contributing risk factors. They also concluded that food addiction may very well be modifiable. Other than that, the authors agreed that in order to understand what mechanisms were responsible for reducing food addiction, and to rightly determine if food addiction presence influences the efficacy of weight loss when it comes to bariatric surgery, further studies are required.