Strategies and Resources for Appealing when your Medical Coverage Allows Weight Loss Surgery but Does not Cover the Duodenal Switch Procedure
By: Amanda Basmajian of Advanced Medical Billing, Inc
I. Does your insurance cover weight loss surgery?
See your HR department for different medical insurance options or shop around independently, perhaps via your state’s exchange for other coverage that offers WLS.
i. Does your insurance cover the Duodenal Switch procedure?
a) Make certain you understand the specifics of your coverage i.e., what criteria is used to determine if you are eligible for WLS and DS. Also, what will your out-of-pocket costs for this procedure be? Your reputable duodenal switch specialist’s office should be able to assist you with parsing your particular coverage.
b) Here is a link that provides medical conditions that must be met to qualify for weight loss surgery by insurance type when a procedure is considered “covered” by your specific plan. Please note: this is just to provide a general idea as contracts vary plan to plan and sometimes a small insurer may hire a large company such as Blue Cross to only process your claims. This may not mean you have Blue Cross coverage. In short: this may provide you with a general idea, but make certain you have your specific coverage benefits obtained from your medical coverage directly.
a) Obtain approval for a weight loss surgical procedure that is covered by your insurance. Then appeal to your medical coverage plan to change the type of procedure to Duodenal Switch. Be prepared to be patient as this process will take some time:
i) Go to your primary care physician and ask for a referral to a surgeon who can perform one of the weight loss surgical procedures that is covered by your plan. (Medical industry experts advise that at this stage you do not mention to your PCP that you’d actually like the duodenal switch).
ii) Initiate prior-authorization for the type of WLS covered by your plan (such as RNY).
iii) While your prior-authorization is pending, find yourself a duodenal switch specialist, and pay out of pocket for a consultation (do not involve your insurance). Request that this physician prepare a letter of medical necessity that is very specific and will address on an individual basis why DS surgery is recommended for you. You will need a letter that details specifically why DS is better for you as an individual patient.
iv) Next, take your approval for the weight loss surgical procedure and immediately submit in writing your request for the duodenal switch procedure instead. Explain that you’ve already been approved for weight loss surgery, so you are only seeking approval for a different type of procedure that will be better for you individually. Make certain to include the letter prepared by your DS surgeon.
v) You will most likely receive a denial from your insurance company. Carefully read the denial to see how to appeal this decision i.e., where to mail the appeal to. Also note the basis for their denial and try to craft your appeal to address that denial. As soon as possible, mail your appeal. This appeal will essentially be exactly like the first letter you submitted, but it will state in the first sentence that you are appealing the denial of the duodenal switch.
vi) If your insurance denies again (and you should expect that it will) your next plan of attack will depend on the type of insurance you have and the state you live in.
a) I have “Self-Funded / ERISA” Medical Coverage provided by my employer: Your employer’s medical coverage administrator has the power to overrule your insurance company. Review the following:
i) Court cases have determined that an ERISA administrator cannot decide to deny benefits if they “offered an explanation for their decision that runs counter to evidence.” (See page 27 of this California Medical Association’s Guide to ERISA: (ERISA) As your appeal has provided quite a bit of evidence, this is good news for you.
ii) Also note that according to ERISA law, your appeals must have either been reviewed by a healthcare professional or a healthcare professional must have at least been consulted. Furthermore, this professional must have been named. (See ERISA page 21)
b) I have an HMO plan and I live in California:
i) Your insurance is regulated by the Department of Managed Care and you are entitled to an Independent Medical Review through this agency: (DMC IMR)
c) I have a PPO plan and I live in California
i) Determine which agency regulates your coverage: Some California PPOs are still regulated by the Department of Managed Care, but others are regulated by the Department of Insurance. Determine which your company is. Be careful! When Anthem Blue Cross states “Life and Health Company” after the name of their insurance they are regulated by Department of Insurance! See this example.
ii) DMC and DoI provide lists of the medical coverage plans they regulate:
Department of Managed Care
Department of Insurance
iii) If your plan is regulated by Department of Managed Care, use the link given above under HMO. If your coverage is regulated by Department of Insurance, here is your Independent Medical Review option through them: (DoI IMR)
d) I do not live in California
i) Use this table which lists the regulatory agencies by state to contact the appropriate overseeing agency for further instructions on how to appeal: (Agencies by State)
Insurance Says DS Investigational
I decided to write Insurance Says DS Investigational: A How-To Manual because of the number of inquiries I have received about how to deal with this insurance obstacle. The general process is pretty much the same for most insurance companies.
First, figure out if your insurance company covers WLS at all. You can usually find this on the insurance company website.
If they do, get a copy of YOUR policy to see whether they cover WLS, as employers can opt out of certain coverages.
If they do, find out (from your HR department) whether your insurance plan is fully funded or self funded. It makes a difference in your route and right of appeal.
If you find out that the insurance company covers WLS BUT says the DS is experimental/investigational, this is what I have found is the way to proceed:
- Ask your PCP to refer you for WLS, and be a good little sheeple and follow all the rules. Don’t mention your desire to get the DS at this point.
- What you are trying to do FIRST is to get yourself approved for WLS in general (likely the RNY), so that when you start to fight for the DS, you are only fighting for WHICH surgery you should have, not whether you qualify in the first place. If you start out asking for the DS with a company that has an exclusion of the DS in their policy, they will make your life miserable at every turn to try and keep you from getting approved for WLS in the first place — they will get hypertechnical with the 6 month diet requirements, with the proofs of being MO for 5 years, etc. They are generally less picky with the RNY.
- Note that in CA, you can avoid the 6 month diet or 10% weight loss requirement by immediately appealing to the CA Dept. of Managed Health Care. But if you don’t fast track that appeal, it will take 4-6 months anyway. I can help you get in contact with the right people at the DMHC if you come across one of these requirements.
- While you are in the approval process for WLS, find yourself a DS surgeon. Get a consult, and pay out of pocket for it. Get a letter written for you by the DS surgeon that explains why the DS is better for YOU than the RNY. This can be because you are SMO, have a family history of stomach cancer, have arthritis or other reasons to need or expect to need in the future to take NSAIDs, have the need to be on anticoagulants, have a Nissan wrap, or some other PERSONALIZED reason. You may as well get the psych consult out of the way at the same time.
- In the meantime, you will be writing your request for the DS for after you are approved for the RNY. You are gathering the papers that show the SUPERIORITY of the DS to attach to your request.
- When you get approved for the RNY, you IMMEDIATELY submit your request for the DS instead, including the well-written letter with your reasons why you want the DS, copies of the scientific literature supporting your reasons, and the letter from the DS surgeon recommending it for you in particular.
- The insurance company will take every day of the permitted period to deny you. You will try not to take this personally (HAH!).
- You will take their denial, and IMMEDIATELY submit a request for a second level review. It will essentially be a copy of the first well written letter, with a request for reconsideration. You will maintain your calm, because there is NOTHING personal about this — it is business (note that I was completely unable to follow this rule and wasted a lot of unnecessary emotion on this part of the process).
- The insurance company will take every day of the permitted period to deny you again.
- What happens next depends on your type of insurance, and possibly which state you live in. If your plan is self-funded, the company ultimately has the power to overrule the insurance company, and your route of appeal is through the company’s HR dept. If your insurance is fully funded, then you likely have the right to external medical review — that information should be provided to you in your second level denial.
- In CA, that review is generally to the CA Dept. of Managed Health Care, which is VERY pro-DS. The process takes about 30-60 days (I believe it’s 30 days from when the DMHC gets a copy of your medical records and appeals from your insurance company), and at the end, they overturn the denial in most cases. The process may vary in other cases, but the important thing is that EXTERNAL medical people will review the case.
More and more, the external medical reviewers are overturning the denials. Don’t let the insurance companies dictate how you are going to live the rest of your life.
See our Articles section for clinical data to support your appeal.