Whenever you are dealing with insurance issues it is important to have a general understanding of insurance ins and outs. The Obesity Action Coalition has a good general guide to the insurance process here. If you are having issues with out of network, out of area, or insurance appeals and denials for Duodenal Switch, there may be some additional assistance from two individuals who have had the Duodenal Switch procedure themselves. We are grateful that they have provided assistance throughout the years to the Duodenal Switch community. The following is their statement on insurance.
The majority of insurance companies are in the business of making money (for profit). They can deny requests for preauthorization with impunity. These denials are often complexly worded and difficult to comply with and overcome, and are definitely overwhelming to the patient, and the busy surgeon’s office. The vast majority of patients faced with demanding if not impossible to achieve prerequisites, or denial of the request for preauthorization simply give up, and the insurance companies pocket the savings.
If you find yourself facing impossible pre-op hurdles, or a denial, we urge you to appeal, and to seek assistance in preparing the appeal. You can hire an attorney, of course, but there is an informal and free resource we suggest that you investigate as well.
If you go to BariatricFacts.org (a non-profit, patient-run site), you will find individuals who are long-term DS postops, and patient advocates. They have been helping patients, pro bono (for free), for over 10 years. They will help you draft your appeal letters, provide supporting medical and legal documentation, and prepare draft letters of medical necessity to be reviewed and signed by your surgeon supporting your appeal. They will not represent you directly, but they will help you best represent yourself. in many cases it is necessary to exhaust all internal appeals (because the insurance companies are unlikely to overrule themselves), and then file for external review, where independent reviewers often overrule improper denials. If you join and then post on BariatricFacts.org asking for help, you will be connected with them and you can decide if you want their help.
Please note that this is just a suggestion. It is neither legal nor medical advice, nor a guaranty regarding their services, and you should always consider getting legal advice and assistance from an attorney who will represent you directly. The members at BariatricsFacts.org will help you draft your own letters, but will not be your legal or medical representatives; you will be required to do a fair amount of your own work on your appeals, and to sign them yourself.
It is suggested that before or at the same time as you contact the resources suggested at the site, you gather as much of the following information as you can:
- A copy of your Evidence of Coverage, which is the usually 100+ page insurance contract between your employer and the insurance company, which you can obtain it from your HR department. If you are self-insured, it will be available directly from your insurance company. Note: it is NOT the Summary of Benefits – it needs to be the contract itself.
- If your insurance is through an employer, you need to determine whether your plan is self-funded or fully-funded. Your rights are significantly different under the two types of plans.
- If your insurance company has a separate bariatric surgery policy, provide a copy of that, too.
- A copy of your surgeon’s request for preauthorization, which provides the ICD-10 and CPT codes submitted.
- A copy of your denial letter, including the section regarding your appeal rights.
* It is strongly recommended that you obtain a copy of your surgeon’s LOMN (letter of medical necessity) before it is submitted to your insurer or for external review, so we can assist your busy surgeon in making the strongest possible case for you.
Don’t be deterred by a denial. It is unfortunately more common than it should be, but it can often be overcome if you meet the requirements for bariatric surgery, if you get help navigating the process.
- Member’s participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member’s participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Records must document compliance with the program; the member must not have a net gain in weight during the program. Note: A physician’s summary letter is not sufficient documentation. Documentation should include medical records of physician’s contemporaneous assessment of patient’s progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member’s participation and progress may substitute for physician medical records; and
- Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists, with a substantial face-to-face component (must not be entirely remote); and
- Nutrition and exercise program(s) must be for a cumulative total of 6 months (180 days) or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least 3 consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of 6 months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.)