Obesity translates into higher health care costs and contributes to disability at all ages.
Obesity is steadily increasing in the United States population and the rate of severe obesity is increasing the fastest. It is estimated that one in three Americans, more than 93 million people, are obese and that more than eight million Americans are morbidly obese.
Obesity has reached epidemic numbers, leading to increased health risks and rising health care costs, yet many insurance companies do not cover weight-loss treatments such as medically managed weight loss programs or bariatric surgery. Although your insurance company should have an interest in keeping you healthy and preventing costly medical expenses, most insurance companies will only pay for costs of obesity-related problems after they develop.
Advocates for obese patients are pressing for change in the health care system to make sure that obesity is treated as a disease and that individuals struggling with obesity have increased access to safe and effective medical treatment. Although many policies have yet to improve, there are many steps you can take now to get your insurance company to cover the necessary medical treatment for obesity.
What is Obesity
Obesity is considered a complex, chronic disease that negatively affects a person’s physical health as well as emotional and mental health. Obesity is determined by measuring a person’s Body Mass Index (BMI), which takes into account height and weight. Adults with a BMI greater than 30 are considered obese; those with a BMI greater than 40, or more than 100 pounds overweight, are considered morbidly obese.
Obesity increases the risk of developing many serious health conditions, including heart disease, type 2 diabetes, hypertension, severe sleep apnea, arthritis, and cancer. Obesity is the second leading preventable cause of death after tobacco use and is associated with four of the ten leading causes of death in the United States; coronary heart disease, type 2 diabetes, stroke, and several types of cancer.
Treatments for Obesity
The rising incidence of obesity has increased the role of doctors and health professionals in the treatment of obesity. While some people are successful at losing weight on their own, participating in a medically supervised weight loss program can provide weight loss and health benefits. In some cases, medical supervision is necessary, such as for patients on a very low calorie diet, for severely obese patients (BMI greater than 35), and for patients with other health problems. While medically supervised programs are expensive, costing approximately $2000 for the first three months, they still cost less than the ongoing costs associated with obesity.
The last resort treatment for morbid obesity is bariatric surgery, any of several procedures which promote weight loss by restricting eating, altering digestion, or both. Depending on the type of procedure performed, the most popular are lap band surgery or gastric bypass surgery, the average cost can range from $15,000 to $30,000. Although this treatment may be recommended by your doctor, many insurance companies are reluctant to cover bariatric surgery.
Gaining Coverage for Obesity Treatment
You can help with the approval process for bariatric surgery by familiarizing yourself with the insurance requirements and providing the insurance company with the proper documentation. Most insurance companies require records of medical history, current health condition including height, weight, and list of obesity-related health problems, and documentation of previous weight loss attempts. Most insurance companies also require a Letter of Medical Necessity from your doctor, which explains your health status, diagnosis of obesity, and recommendation of bariatric surgery for treatment. Most bariatric surgeons are experienced at working with insurance companies and your doctor should be more than willing to help you work through the approval process.
During the approval process, it is important to keep copies of all medical documents and correspondence from your insurance company. If your first request for pre-authorization is denied, you have the option to appeal, but it is necessary to have all your paperwork in order. If you get a denial from your insurer, make sure you get a denial notice in writing listing the exact reason(s) for denial. Many times a denial is based on missing paperwork or unmet requirements. As timing is an issue, not only is it necessary to provide the necessary documentation, but make sure you file the appeal in a timely manner.
If your insurance policy has an exclusion for “obesity surgery” or “treatment for obesity” you may still be able to appeal and gain approval for bariatric surgery. Bariatric surgery is now recognized as an effective treatment for other life-threatening disorders, including type 2 diabetes, hypertension, or heart disease. As these are usually covered health conditions, your appeal would be based on your doctor’s Letter of Medical Necessity that states the need for weight loss surgery to treat one of these covered diseases.
Throughout the approval process for obesity treatment, you will need to be your own best advocate. The insurance company may not make the process easy, but it is important that you don’t give up. When dealing with the insurance company, it is important to be pleasant and polite, yet persistent and determined. In making their decision, the insurance company needs to be convinced that you qualify for surgery and that it is the most effective type of treatment for your personal health situation. Many patients have followed the insurance process through to the end and have successfully gained approval for bariatric surgery.
If you need additional information or help in getting approval from the insurance company, you may want to contact the Lindstrom Obesity Advocacy (www.wlsappeals.com) for legal advice and reimbursement support. Another helpful website that you may be interested in visiting regarding Obesity Advocacy is the Obesity Action Coalition (www.obesityaction.org). We have no affiliation with either of these resources but they appear to be effective advocates for individuals affected by obesity.