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Insurance Verification
Submission Requirements
Appeals and Patient Financing

Our Our program accepts all insurance carriers accepted by New York Methodist Hospital. Please call Rosina Ciappina (718-836-4258) to verify if your insurance is covered.

The program currently accepts the following insurance:

Aetna Health Plans
Affinity Health Plan
AmeriChoice of New York Personal Care Plus
Amerigroup New Jersey New York
Beech Street Corporation
Blue Cross  Blue Shield PPO
Blue Cross Blue Shield HMO
Blue Cross Blue Shield Senior Care
CIGNA
First Health now Coventry Health Care National Net
Galaxy
GHI Medicare Choice PPO
GHI, GHI HMO , GHI HMO Select
HealthFirst
Health Plus PHSP Inc
HIP Health Insurance Plan of Greater New York
MagnaCare
National Benefit Fund 1199
Neighborhood Health Plan
Oxford
PHCS
RailRoad Medicare
United Healthcare
Wellcare of CT and NY
Medicaid of New York /Computer Science Corp.
Medicare of New York - Downstate

Insurance Coverage Verification
To determine if your insurance policy covers obesity (or "bariatric") surgery, refer to the insurance policy package.

Typically, there are two sections that describe the extent and limits of coverage. The first is usually called "What Is Covered" or "Covered Expenses." These are the healthcare benefits for which the company will pay. The other section is "What Is Not Covered" or "When the Plan Does Not Pay Benefits." In this section, look for any statement that the company excludes coverage for weight control, for the treatment of obesity, for the surgery for weight control, or for the complications of the surgery for weight control. Some policies will outright exclude bariatric surgeries. Others may have certain parameters around which bariatric procedures they cover and how much of the costs they cover. Look for statements such as, "Surgery for the treatment of obesity is covered when deemed medically necessary," or "Surgery for the treatment of obesity is (specifically) excluded except when medically necessary." If this surgery is a covered benefit when medically necessary, then it should be covered when patients meet national guidelines for care for morbid obesity.

We may be able to verify for you if your insurance plan covers bariatric surgery. There is a small charge to cover our administrative costs. Please note that this in no way insures that you meet eligibility criteria or that you will be covered -- it's provided for informational purposes only.

Insurance Precertification: Submission Requirements
A Letter of Medical Necessity and weigh-loss history are necessary to obtain prior authorization for obesity surgery. A Letter of Medical Necessity states why significant weight loss is medically necessary for a patient and usually includes the following information:
  • Patient’s weight and BMI (which should be 100 pounds or more above ideal weight or a BMI more than 40 or at least 35 with associated medical problems to qualify)
  • List of medical problems associated with obesity, such as type 2 diabetes, sleep apnea or hypertension among others.
  • Number of years patient has been overweight (which should be at least five or more)
  • Number and types of failed weight-loss programs attempted in the past
  • Record of physician supervised medical weight loss for 6 months – this requires your doctor to provide documentation of having seen you for 6 consecutive months or two periods of 3 consecutive months within the last 2 years.

If you create a document or packet listing all your weight-loss attempts (self-controlled or medically supervised) and their results, you can further support the preauthorization application. You should include any commercial diets or medical records of your weight-loss efforts.

Appeals and Patient Financing
If coverage has been denied on the initial prior authorization request, Dr. Thodiyil may speak to the medical director of your insurance company in support of your application. If the denial was based on any correctable deficiency, we will work with the patient in addressing these issues and then resubmit the application.

It will be rare and unusual for you to have to contact a lawyer with expertise to help you with the appeal. More information about legal help can be found at The Obesity Law and Advocacy Web site at www.obesitylaw.com.

When insurance reimbursement is not available, patient financing is another alternative you may consider. Please ask us about available patient financing programs during the patient seminar or your office visit.