How Does Insurance "Approve" Medical Records for DS?

on 5/13/11 1:57 am

How does insurance “approve” medical records for DS?  What exactly, are they looking for to place their seal of approval on it?  What are the criteria?

For instance, if someone were to submit a claim for a WLS revision to DS, then the insurance company would be looking for what in the medical records?

Do they want to see a steady increase in weight?  Do they want to see weight go up and down?  What are the parameters they are looking for in order to approve a DS revision?

I’m assuming there is a claim specialist or computer sitting at a desk somewhere looking for specific numbers.  What are those numbers?

I imagine they are looking for other things, too, like compliance with existing WLS.  So, anybody that admits that they, in a 1/2 decade, had an after dinner mint will be considered non-compliant and rejected?  I honestly don’t know.

Is there anybody that has gone through a revision that can help with what they were told by their insurance company, or that they figured out on their own, were “do’s” and “don’ts” on their successful road to revision?  How can someone best prepare to give the insurance company what it needs for a successful approval for a revision to DS?


on 5/13/11 9:16 am - bay area, CA
I'm not the best person for this question, but I think you are making it more complex than it needs to be. Your policy is a contract. It should specify whether or not bariatric surgery is covered at all, and if so, whether or not revision or second time around bariatric surgery is covered. Some policies now have  "one wls per lifetime" language. Others will state that a second operation will be covered only if there is a complication or malfunction of the original operation. Others are more generous.
     So rather than looking to the specifics of your own cir****tances, read the policy, or potential future policy, for guidance. At least that's a good starting place. If revision wls is covered, THEN you need to consider whether or not you still meet the NIH criteria, etc.

on 5/14/11 3:43 pm
Thank you.
on 5/13/11 9:38 am - Kennewick, WA
I would suggest calling your insurance company and hash out the details. Make sure to have a notebook and write everything down. Even the name of who you're speaking with. Since they're the ones that set the rules, they'll be the ones to talk to about it.

I hope you are able to get your surgery.
on 5/14/11 3:44 pm
Thank you.
on 5/14/11 7:11 am
Revision on 06/21/13
Call your insurance and get a copy of what is cover for WLS under your policy. They should be able email, fax or snail mail it to you. Then go thru it with a fine tooth comb and see what the requirements are to have surgery.
Like others mentioned, some policy's have a once in a lifetime. Others have revisions for specific reasons. It really varies. It also varies by what state you are located in. I do not see where in the US you live. California  for example has an excellent record of the insurance commission turning over refusals to approvals.

 Revision #2 Dr John Rabkin June 21, 2013; First Revision DS - Dr Maguire
  5-18-09; First DS 7-15-2003 Dr Clark Warden = Third time is the charm   



on 5/14/11 3:44 pm
Thank you.