Assessing Your Insurance Coverage of Morbid Obesity Treatment

Okay, you are halfway there now! It is now time to review your policy and see what/if any morbid obesity treatment options are available. You need to familiarize yourself with your plan documents. This will help you when trying to work with your insurance provider contact, and remember to get everything in writing when speaking with them.

In the event weight-loss surgery is not covered, write your employer’s benefits manager and explain to them the impact morbid obesity has on your life and how having access to treatment would improve the quality of your life. (For a sample letter, please click here.)

Insurance Provider and Reviewing Claims

Your insurance provider very carefully reviews your claim and looks for two main things:

• Which procedure/benefit are you trying to access

• Reason why you are you accessing this benefit (if available based on your policy restrictions/exclusions)

The procedure/benefit you are trying to access will be coded using a CPT code. These codes originate from the American Medical Association and allow physicians to record the treatments provided to allow for processing of your claim.

The “reason” for the treatment will be represented by an ICD-9 code. This tells the insurance company your doctor’s diagnosis and why treatment is needed. These are the codes and processes used to determine whether or not a claim will be covered under your policy.

If the codes were incorrect, obtain the correct codes and a letter from your doctor, and resubmit your claim. An incorrect coding error could impact your claim and deny reimbursement.

Below please find samples of CPT and ICD-9 codes.

Difference Between CPT Codes and ICD-9 Codes

Sample CPT and ICD-9 Codes
Please note that the below codes are provided as an example. Codes often change, so check with your surgeon’s office for the most current codes.

Pre-Approval of Your Procedure
Typically, your surgeon’s office will submit the necessary information to your insurance provider in order to seek pre-approval. However, if they do not, below, please find an example of the necessary steps.

Pre-approval is almost always required for weight-loss surgery. If possible, it is best to gain approval for your procedure. This is an excellent way to make sure that this procedure is covered under your contract.

It is best to contact them in writing and request a determination of your coverage amount prior to your procedure (to ensure receipt of your letter, send it by certified mail and file a copy of the individual’s signature who accepted it). Again, make sure to request this in writing (For a sample letter, please click here).

Make sure to follow-up with your insurance company. If you have not received anything within a week of speaking with them, call back and confirm your materials have been received.

Next - Appealing a Denial