Many times patients who do not have coverage for weight loss surgery will ask us to file an appeal. Will this work? The short answer is no. Read on for the long answer…
If your insurance does not cover weight loss surgery, this is called an “exclusion.” This means that the employer who provides the insurance chose to exclude surgical weight loss from coverage in order to purchase a cheaper plan. Once you understand this fact, it’s easier to understand why you can’t file an appeal and get them to cover it, no matter how severe your obesity might be.
If insurance companies were to allow this, then no employer would ever opt for the more expensive plans that do cover bariatric surgery. They would just buy the bare bones coverage and then tell their employees to all file appeals to get it covered anyway.
Unfortunately, when patients call their carriers, someone on the other end of the line (who actually works for the insurance company) will tell you that you can file an appeal. This is technically true, as you can file an appeal for anything your insurance denies. However, in this case the appeal will never work because the issue is not one of medical necessity; in otherwords the insurance company is not saying that you don’t need the operation, they are denying it because you do not have the right type of coverage. It would be somewhat like having a tree fall on your house and asking your car insurance to pay for it. Or, perhaps more appropriately, asking your homeowners to pay for flood damage when it is specifically excluded from your homeowners policy. It simply isn’t going to happen.
Also unfortunate (at least in Ohio, Kentucky and Indiana) is that marketplace policies purchased by individuals under the Affordable Care Act also exclude weight loss surgery. Medicare, Medicaid, and most managed-care Medicaid plans such as CareSource, do cover weight loss surgery, however.
We wish that all Americans had access to life-saving surgical weight loss procedures, and maybe some day that will happen. In the meantime, patients with exclusions essentially have two options:
- consider self paying for surgery
- look into a more affordable option such as one of our appetite suppression programs