Reasons to be Denied Weight Loss Surgery

Reasons to be Denied Weight Loss Surgery

Although bariatric surgery is a life saving procedure for many patients, insurance companies often try to deny coverage to policyholders on various grounds. Many people struggling with obesity want to know how old do you have to be get weight loss surgery. In reality, this procedure can be successfully performed even on eligible adolescents, but teenage is one of the reasons insurance companies deny bariatric surgery.

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How do I qualify for weight loss surgery?

Any woman or man with a BMI of 40 or higher, or a BMI of at least 35 with co-morbidities is usually eligible for a weight loss surgery. But being medically qualified for this procedure does not automatically mean that you will receive a gastric sleeve approval or gastric bypass approval from your insurance company.

Compliance with the insurer’s conditions

While your insurance policy may not specify how old do you have to be to get weight loss surgery, the insurer will generally require you to be at least 18 years old to be eligible for coverage. You should carefully review the terms and conditions mentioned in your “certificate of coverage” which is provided by the insurer at the time the policy is issued.

Recommendation from a bariatric surgeon

Once you are sure that your insurance policy covers bariatric surgery, you should meet a qualified surgeon to determine your candidacy. The surgeon will review your medical history, check your BMI, and examine your general health condition before giving you a letter of recommendation for a weight loss procedure.

Obtaining authorization from the insurer

One of the reasons insurance companies deny bariatric surgery coverage is that patients are unable to show that their diet and exercise attempts failed to eliminate obesity. Secondly, some insurance providers may want you to go through a physical and psychological evaluation from their own doctors – and be cleared. Therefore, the authorization process can be uncertain and time-consuming.

SEE ALSO: Bariatric surgery requirements: Do I qualify for weight loss surgery?

How old do you have to be to get weight loss surgery

Eligible candidates in the age group of 14 to 70 will usually qualify for a weight loss surgery. However, when it comes to obesity among adolescents, many parents are concerned whether their child is fit to undergo this procedure. It is best to ask your surgeon how old do you have to be to get bariatric surgery. If you have insurance coverage, you should also check with your insurance company whether they have a weight loss surgery age limit.

Gastric sleeve age limits

According to the American Society of Metabolic and Bariatric Surgery (ASMBS), gastric sleeve surgery is one of the key procedures being performed on teens with obesity. The BMI criteria are applied differently for determining a child’s eligibility for VSG surgery. Among adults, there are no specific gastric sleeve age limits, but the surgeon will determine whether the adult is physically and mentally fit to undergo the procedure.

Gastric bypass age limits

Gastric bypass is a relatively more invasive surgery compared to a sleeve gastrectomy. However, if an adolescent is suffering from severe obesity and type 2 diabetes, they could qualify for gastric bypass surgery in their teen years. A pediatric evaluation may also be required. Gastric bypass age limits do not apply to adults, but the bariatric surgeon will consider whether the patient is medically fit to sustain general anesthesia, surgery, and intestinal resection.

Age limit for lap band surgery

Gastric band surgery is relatively less invasive, which makes it easier to qualify for this procedure. The lower age limit for lap band surgery would generally be 13 or 14 years, while there is no specific upper age limit. However, some insurers may not give lap band surgery approval because of the relative inefficacy of the procedure. This could be one of the reasons insurance companies deny bariatric surgery if the policy terms exclude a particular type of procedure.

Gastric bypass approval

One of the common reasons insurance companies deny weight loss surgery is that the patient fails to follow the prescribed procedure for coverage approval. Here are a few simple steps that should help you obtain gastric bypass approval from your insurance provider.

  • Step 1: Your insurance provider is legally required to give you a “certificate of coverage” when you take out the policy. You should begin by reviewing this certificate carefully. If you cannot find it, talk to your insurance agent or your employer’s HR team for assistance.
  • Step 2: Seek an appointment with a general physician who may refer you to a weight loss surgeon. If you know a bariatric surgeon, you may directly visit them as long as your insurance company does not require you to begin with a visit to the general physician.
  • Step 3: When you visit the bariatric surgeon, remember to carry your medical records and details of your previous failed attempts to reduce obesity through diet and exercise. During the consultation, you can ask them how old do you have to be to get weight loss surgery.
  • Step 4: If your surgeon gives you gastric bypass approval, they will complete the necessary documentation to receive surgery pre-authorization from your insurer. If you have obesity-related type 2 diabetes, it gets easier to obtain gastric bypass approval from the insurance company.

RELATED: How to get weight loss surgery approved?

Gastric sleeve approval

If you are within the generally accepted gastric sleeve surgery age limit of 18 to 70, it will be easier to obtain gastric sleeve approval from your insurer. If your age is under 18, your surgeon may still qualify you as a candidate, but you may be denied insurance coverage. Here are the steps involved in VSG approval.

  • Step 1: Different insurance companies may have different types of insurance plans. You should begin by reviewing the terms and conditions of your insurance policy to understand the gastric sleeve approval requirements and coverage benefits provided to you as a policyholder.
  • Step 2: Collect all relevant medical documentation, including your medical history, diet and exercise records or a journal, and medical test reports if recommended by your physician. Schedule an appointment with a qualified weight loss surgeon once you are ready with the documents.
  • Step 3: Obtain a letter of recommendation from your bariatric surgeon and submit it to your insurance carrier along with all other necessary documentation. Ask your insurer about a status update on your application, and if there is a delay, seek help from your employer’s HR team.
  • Step 4: If you initially fail to obtain gastric sleeve approval from your insurance company, check the reasons insurance companies deny bariatric surgery and try to plug the gaps, if any. You also have the option to file an appeal with insurer to re-consider your request for pre-authorization.

CHECK THIS: Indications for bariatric surgery

5 Reasons to be denied weight loss surgery

While weight loss surgery is a transformative procedure for people struggling with obesity, it is not for everyone. There are a number of reasons to be denied bariatric surgery. Sometimes your surgeon may qualify you as a candidate, but you may still be denied insurance coverage for this procedure.

  • Age: Although there is no specific gastric bypass age limit or gastric sleeve age limit, in general these procedures may not be performed if you are below 13 years of age or your body is still developing. Similarly, people above the age of 70 or 75 may be denied bariatric surgery.
  • BMI: If your body mass index (BMI) is below 40 without co-morbidities or below 35 with co-morbidities, it is one of the main reasons to be denied weight loss surgery. However, there are exceptions to this rule, and some patients with a BMI of 30 or above may be accepted as candidates.
  • Health: If you have an untreated stomach infection, an advanced lung or liver disease, active cancer, or another serious illness that could pose risk to your safety during or after the procedure, you may be denied a weight loss surgery approval. Once the symptoms reverse, you may again try to qualify.
  • Smoking: Your surgeon will require you to quit smoking at least a few weeks before the scheduled bariatric surgery. Nicotine in tobacco smoke can constrict your blood vessels, and increase your risk during surgery or interfere with your post-operative recovery.
  • Diet: Pre- and post-op bariatric diet is a critical element in the safety and success of your weight loss surgery. Your gastric sleeve approval or gastric bypass approval is contingent upon your commitment to follow the prescribed dietary guidelines before and after your surgery.

CHECK THIS: Apply to see if you qualify for weight loss surgery

Reasons insurance companies deny bariatric surgery

Reasons to be denied weight loss surgery can vary widely. Sometimes the coverage may be denied even when your bariatric surgeon has certified you as a candidate and presented clinical evidence that you need this procedure as a medical necessity. Here are some of the common reasons insurance companies deny weight loss surgery.

  • Your age is below 18 years, even though you are medically qualified to undergo bariatric surgery.
  • Your health insurance policy specifically excludes coverage for obesity surgery or obesity treatments.
  • You fail to clear the insurance company’s authorized medical or psychological evaluation for this procedure.
  • You fail to present proof of a medically supervised diet and exercise program showing that it was unsuccessful in eliminating obesity.
  • You are denied coverage on technical grounds if you do not submit one or more of the documents required by the insurer for approval.
  • A clerical mistake causes coverage denial (which can be overturned if you file an appeal with your insurance company).
  • You are unable or unwilling to make payment for the deductibles and/or co-pays as stipulated in your insurance policy.
  • Your medical history shows you are an unfit candidate (one of the common reasons insurance companies deny bariatric surgery).

READ THIS: Weight loss surgery procedures

What to do when you are denied for a weight loss surgery

When you pay your insurance premiums on time, you have a right to receive coverage for bariatric surgery, it is a covered procedure. However, in reality, insurers may find a variety of reasons to deny weight loss surgery coverage. Here are some of the things you can do when you are denied for a bariatric surgery.

  • Talk to the benefit administrator in your employer’s HR team if your health plan is provided by your employer.
  • Consult with your bariatric surgeon to understand which specific eligibility criteria you may have failed to fulfill.
  • Complete a peer-to-peer eligibility review if the bariatric surgery is covered under your employer’s health plan.
  • Work on the specific areas to reverse the reasons insurance company denied weight loss surgery coverage.
  • Submit revised documents to your insurer or file an appeal to obtain your weight loss surgery approval.
  • If you were denied for a weight loss surgery because of a failed psychological assessment, get an independent evaluation done.
  • Raise the issue of your insurance coverage denial on public forums and social media in a fair yet persuasive manner.
  • Hire an attorney who specializes in insurance claims and recoveries and has experience in bariatric surgery insurance denial cases.

Final words

Are you wondering how old do you have to be get weight loss surgery? Do you want your insurance company to pay for your gastric sleeve or gastric bypass surgery? Remember that persistence is the key that will open doors of opportunity when you are facing insurance coverage denial for bariatric surgery. You have a right to undergo this life-changing procedure and reclaim your health and quality of life.

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