7 Tips for an Effective Insurance Appeal

October 13, 2014

The insurance process can be frustrating and confusing for many reasons. Insurance polices vary greatly by employer, or even geographical locations. Even taking pro-active measures to get authorization for surgery might not guarantee payment of the claim. Most surgeons' offices have staff that handles insurance authorizations, however, it would be impossible for one person to know all the coverage guidelines for all the insurance policies and insurance companies. Some offices may assist with appeals, while others might leave it up to the patient. If you find that insurance denied your weight loss surgery, you do have several options, one of which is to appeal the decision.

Here are some tips for creating an effective insurance appeal:

Know Your Policy - Request a current copy of your Plan Document (Certificate of Coverage) so you will know all the terms and conditions of your coverage. This will tell you what services and treatments are covered and any exclusions of the plan. Typically this is provided to you by your Human Resources department either in a printed version or online (pdf). This is the contract between the insurance company, your employer, and yourself. *Also request the specific policy related to Treatment of Obesity and/or Plastic and Reconstructive Surgery. These are additional documents from the insurance companies that outline their specific guidelines for coverage. Some policies might be available online by  doing an Internet search of the insurance name and "treatment of obesity".

Know the Reason for Denial - You cannot effectively appeal the decision unless you know the reason the insurance company denied your surgery. The denial notification should be provided in writing stating the reason. If not mentioned with details, request more information, also request the guidelines and specific policy used to make the determination. You can request this additional information by calling the Member Service phone number printed on your insurance ID card.

Focus on Facts - Once you have the reason for denial and the insurance policy you are ready to draft your appeal letter. Insurance companies are only interested in facts that pertain to the requested procedure, not your feelings about being denied. Focus on the facts of the policy requirements and how you met those requirements. If insurance required pre-op diet and psychological consult list the dates of when the requirements were met in your letter. While you want to clearly explain your situation, you also want to be as specific and to the point as possible.

Show Medical Necessity - Medical Necessity is the key to coverage approval. The policy guidelines will outline the criteria for which the insurance companies consider a surgery to be medically necessary. Describe your current medical issues as they pertain to the medical necessity guidelines of your policy. Many companies have lists of which medical conditions they consider to be co-morbidities to obesity.

Documentation - All facts to support medical necessity need to be documented: physician notes, test results, consultations, pictures. Documentation is key. In addition to documentation that support medical necessity, it is also important to document your appeals process.  Make a note of every call you make to the insurance company. You may need to get records from many doctor offices, it is best to request copies of the records for yourself verses having the office send them to the insurance company. This allows you to make sure all needed documents are included in your appeal submission. Note: Doctor offices and hospitals are permitted to charge for copies of medical records.

Submission - Once you have your letter and all other documents, organize them into a packet starting with the letter and then place documentation in order as referenced in the letter or by provider (ex. all doctor visit notes, nutrition visit, sleep study). Put your last name or initials on the bottom of each page and number the pages. Make a photo copy of the entire packet for your own records. If you fax your packet be sure to keep a copy of the faxed transmission. If you mail the packet be sure to mail with some type of tracking and delivery confirmation. Appeals are time sensitive so you want to be sure you have proof of when you submitted your appeal.

Keep fighting - Read your insurance’s process for appeals, it should be outlined in the denial letter. There are several levels to the appeals process and each level has its own process and time limits. It may take more than one appeal to overturn a denial, do not  get discourage. Some patients opt to contact a lawyer for assistance with the appeal process.



Sarah (aka Sarahlicious) has been an active member of ObesityHelp since 2003. Her specific areas of interests are Lipedema, Lymphedema, Obesity, and Health Insurance advocacy. Sarah writes about her life experiences at Born2lbFat. She is a member of the Board of Directors of both the Obesity Action Coalition and the Lymphedema Advocacy Group. Sarah has a Masters in Health Law.

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