Surgical Weight Related Denials
Related Denials, Lap Band, Gastric Bypass and Abdominoplasty
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Many health plans consider paying for weight related surgical procedures as being cosmetic or not medically necessary. However, these procedures often are performed to alleviate a patient from real medical symptoms.
For most appeals, you are going to need the assistance from your physician to provide statements of medical necessity.
You must also obtain an authorization where required by your health plan.
Your symptoms/diagnosis required for the surgical procedure must be specific and detailed by your physician in your medical chart.
Denials could be properly appealed depending upon the support by your physician proving medical necessity and the focus of your argument within the appeal letter.
How do you combat a surgical denial? The following steps may help.
Review the denial with your policy booklet and verify that their denial is justified. If their reason for denial is unclear, call the customer service unit at the health plan for a more descriptive explanation. Record your conversation and document the name of the individual you spoke with for future reference.
Does your health plan cover the specific surgical procedure and did you abide by the policy and limitations by the plan?
If you received an authorization, this will help. However, if you are appealing to get this procedure authorized, you must still prove medical necessity.