Gastric bypass insurance coverage
The number of severely obese people in the United States is increasing. Hence, there is an increasing need for gastric bypass surgery. Thus, insurance companies have included coverage for gastric bypass surgery in their policies where they are medically essential. The National Institute of Health has specified guidelines for weight loss surgery. As per these, a patients Body Mass Index must be minimum 40. Those having this index between 35 to 39.9 along with a serious obesity-related health issue like heart disease or type II diabetes, are also accepted for surgery.
Requirements
After the surgeon accepts that gastric bypass surgery is essential, the patient must get approval from the insurance company. This company sends a list of requirements that is customized to the policy. It is possible to check the policy bulletin online for a particular company. The insurance company generally asks for the following a detailed diet history, current height, current weight, current body mass index, a list of co-morbidities caused by the morbid obesity, a psychological evaluation or clearance, a complete medical history, internal medicine clearance, a recent medically supervised diet history, medical records that support the history of morbid obesity and some medical tests.
Documentation
The insurance company requires a physicians documentation as an evidence of morbid obesity. The physician can supply copies of the patients visit records that are a proof of ongoing weight issues.A letter from the physician stating that the current obesity is unacceptable is demanded by the insurance company. Also, documents from the past and present physicians who have treated may also be attached.
The insurance company may demand records of medications which the physician has recommended for loss of weight. Also, records of any diet program that the patient may have participated in would be necessary. The patient may be taking advice from a licensed psychologist or psychiatrist. If currently there are advised medications for mental health, the insurance company would ask for a psychiatric evaluation to be eligible for coverage. The reason is that although genetics and metabolic rate have an effect on the weight of a person, it is frequently found that emotional and psychological problems have a bearing on obesity. As a matter of fact, if these issues are not considered before or during the surgery, the patient may develop serious complexities. Thus, all insurance companies demand a medical and psychological clearance prior to the approval for surgery.
Depending on the type of insurance, the patient may be asked to give a referral or stay within a network of providers. The request for coverage may be negated if the required documentation is not supplied.
Expenditure
The insurance company pays expenses from 50 to 100 percent of the hospital and doctor fees. Some policies also include the charges of in-house nursing care after being discharged from the hospital, if this is felt essential by the physician and is approved by the insurance company.
There are different types of expenditures concerning gastric bypass surgery like tests to determine eligibility for the surgery, pre-admission testing, in-hospital costs, surgeon and other doctor fees and post-surgery medication and care. If the insurance company does not cover the actual procedure, it may cover one or more of the related costs.
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