What does deemed "medically necessary"......?

Question

My sister wants to get the gasteric bypass surgery... she is about 370lbs and all other health plans have failed.... the surgeon is ready, she called the insurance company and they said the only way they would approve the surgery would be if it was "deemed medically necessary" What exactly does that mean? How does she prove that?

Answer 1

Medically necessary -> means that the insurance will only cover once the procedure is badly needed for the patient . Or She is really needing the surgery.

The only way to prove that is to gather all the medical records from the surgery... you may need to get authorization so pls contact your insurance just to make if you need one..... Provide medical records... all the records that you have will help a lot..... this will also help the processing of the claim and it will be reviewed straight my medical review as well....

Answer 2

basically it means it is necessary she has the surgery.  in other they don't want to pay for a procedure just because she wants to have it done. does she have a disorder that doesn't allow her to lose weight naturally? can she lose the weight with diet and exercise? her weight has to be effecting her health to the point if she doesn't have the procedure soon it could  kill her.

Answer 3

hear it everyday....

Insurances will only cover benefits that they consider medically necessary based on your diagnosis, and cure/treatment ....

Anything else, they will review or deny ...

you can always appeal

Answer 4

her physician would have to write a letter saying that the surgery is medically necessary because she is at risk of death or disease due to her weight.  Otherwise it is deemed cosmetic in nature - and therefore not necessary.

Have her see her physician - if the physician agrees to write a letter she can send it to the insurer.  Do this before having  the surgery.

Good luck!

Answer 5

The insurance company should have a list of criteria under which they would consider a gastric bypass "medically necessary."  Your sister and/or her physician should request a copy of that criteria.  The physician would need to assist her in submitting a request to the insurance company (often called a "pre-determination").

Here's an example of one company's criteria:  http://provider.medmutual.com/TOOLS_and_...

Most likely, your sister's insurance company will have very similar requirements.  (Of course, she needs to get a copy of their policy to know *exactly* what criteria she'll need to meet.)

If you take a look at the document I linked, you'll see that she'll likely need to prove things like a documented attempts at non-surgical weight loss, medical conditions being caused by her weight, passing a psychological exam, etc.  (Again, get a copy of her insurer's criteria, so she knows exactly what to expect.)

Her physician will need to assist her in gathering this documentation and should be able to walk her through the pre-determination process.

Answer 6

Have your sister's doctor call the insurance company and ask what they need to get the surgery approved.  They might need the written statements of several physicians that this surgery is medically necessary, in other words if it isn't done her life is threatened.

Answer 7

What happens is the patient goes through a battery of tests both physical and mental.  The doctor then goes over the tests results with the insurance company doctors. A decision is made by the insurance company doctors if it meets the criteria set out by the insurance company if the procedure is  medically necessary or not.

Answer 8

Well, medically necessary usually means, you need to have it done for your health, AND, there isn't a non-medical way to get it done.

Unfortunately, there IS a non-medical way to lose weight - it's called dieting, and it requires a lot of self control, and it isn't fun.  If she limited herself to 1500 calories a day, she WOULD lose weight.  Period.  

Also, the insurance companies look at long term results.  I saw a recent study that showed five years after gastric bypass, 85% of people weighed as much, or more, than they did before.

Bottom line - it's a quick fix, but not a permanent one, and it has some serious medical risks (like, you can DIE from the surgery), and it doesn't solve the problem long term.  The only thing to solve the problem long term, is a behavior change.

She can call her insurance company, and ask how she proves it's medically necessary.  Usually it involves joining weightwatchers for a year or two, excercising, dieting, and proving that she's made a serious effort to lose weight.