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Managing An Insurance Denial

Many of our patients have insurance coverage for their bariatric surgical procedure. And while we would all hope that the insurance process were very simple and straightforward, there are hurdles that we have to overcome to ensure coverage. First and most importantly, while the insurance company may cover bariatric surgery in some of their plans they may not in others. So, the first step is to learn that coverage is, in fact, afforded by your policy. You can do so by calling your insurance company or agent or speaking to the HR director at your company. We can also assist you in verifying your benefits, so feel free to lean on us if you have any trouble understanding your policy.

Next, you’ll want to ensure that you have met all of the qualifications required to undergo bariatric surgery. Each insurance company has their own specific set of criteria for approving patients. This may include proof of failed diets, extensive pre-operative testing and even participating in a medical weight loss program for a period of time. It is therefore important to contact them and work closely with us to ensure that all of the requirements have been met.

Third, when submitting a preauthorization it is important to fill out the required forms accurately and completely. Even a small oversight may trigger a denial.

With this said, it is important that you do not panic or worry if your insurance company sends a denial. It can often be reversed by correcting the problem and resubmitting the paperwork. Follow these important steps if you receive a denial:

  • The first and most important course of action is to get the denial in writing along with the reasons for the denial, if your insurance company has not done this already.
  • Review the denial and send it to your bariatric surgeon and primary care physician
  • With the help of your medical team, correct the issues identified in the denial letter
  • Resubmit the appropriate paperwork

If, for some reason, we cannot overturn the denial, there is an appeals process that allows you to seek a reversal through the state of California. At this point you may also want to enlist the assistance of a patient advocate.

Ultimately, you shouldn’t fret a denial, especially if your situation qualifies for coverage. While the process may be frustrating you have plenty of resources to lean on to get approved!

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Santa Monica Location
2001 Santa Monica Blvd
Suite 1170W
Santa Monica, CA 90404
Tarzana Location
5525 Etiwanda Avenue
Suite 222
Tarzana, CA 91356