Prior Authorizations and Appeals

[stpatty 18]

Who should submit the prior authorization? Me, primary physician, or surgeon?

My insurance policy does not include bariatric coverage, so I was going to appeal the expected denial but I need a denial first.

Has anyone ever had experience or heard of anyone getting coverage when their policy excludes it?

Thanks!!

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[Bufflehead 6,358]

No, I've never heard of anyone getting coverage when their insurance specifically excludes bariatric surgery. Your insurance coordinator for your surgeon is probably the best source of information though.

Who submits for pre-auth will depend on your policy, but should be either PCP or the surgeon, not you. Again, your surgeon's insurance coordinator should know the answer for sure. Good luck!

[stpatty 18]

Thanks! I think I need to find another surgeon because the IC has been less than helpful so far.

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[KristenLe 5,979]

@@stpatty It would be very unlikely you could appeal for an excluded service. I don't think an appeal will even be allowed. You could try fighting with your employer to have it covered. Look at the Obesity Action Coalition website for guidance.

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