Five Tips For Getting Weight Management Treatments Covered By Insurance

By Melinda Maryniuk, MEd, RD, CDCES

According to the Canadian Adult Obesity Clinical Practice Guidelines, there are three things that have been shown to be effective for losing weight and keeping it off in the long-run: medications, bariatric surgery, and psychological interventions like cognitive behavioral therapy (or CBT). Unfortunately though, insurance often doesn’t cover these options (or there are long wait times to receive care, especially bariatric surgery) even though their effectiveness is well-documented. What can we do about this?

Educate yourself. Obesity is a chronic medical condition and it’s recognized as such by the American Medical Association, the Canadian Medical Association, and the World Obesity Federation. Many insurance companies haven’t incorporated this reality into their benefit plans and may benefit from being educated about why medications & surgery are some of the few proven long-term treatments for obesity.

Learn about all the benefits offered by your health plan. Read the benefits handbook or explore the member services section of the website. You may also talk with the benefits manager in the Human Resources department of your employer. You may be surprised to learn that your insurance plan covers more services than you might have realized – many insurance plans have benefits for things like gym memberships and diabetes education classes.

Check periodically. Formulary coverage of different classes of medications frequently change. Even if your insurance hasn’t covered anti-obesity medications in the past, it’s a good idea to check periodically to see the current status of coverage.

Keep good records.There may be times when you need to document “medical necessity.” That means, you show proof you need something specific for your health. For example, if your weight is impacting your health (ie. causing sleep apnea, joint pain, or elevated blood glucose), your physician may have a stronger case to make about why a medication or procedure should be covered.

Don’t take “no” for an answer.If a treatment you’re interested in is not covered, sometimes exceptions can be made. Explore these steps:

• Review your healthcare options including your and your spouse’s plan coverage. Evaluate if a plan change is needed during the Open Enrollment period.
• Talk to your employer about if they’ve considered covering obesity treatments as part of their benefits package, and direct them to the Canadian Adult Obesity Clinical Practice Guidelines to learn more about why this is important for the health of their employees.
• Learn the reason why a treatment may not be covered. Is it a decision by the insurance company or your employer?
• Ask about the formal exception process. Each health plan has a standard appeals process. Review your “evidence of coverage” for appeal steps. Most insurance companies allow you or your provider to file an appeal within 180 days. When writing the appeal focus on all the medical reasons this treatment should be covered and provide as much documentation as you can.
• Talk with your doctor or healthcare provider to establish a strong reason why you may benefit from a different treatment. It’s usually best to meet with your healthcare team to discuss this and be prepared to show reasons why this is important to you (for medical and personal reasons).
• Remember that even if your insurance company has denied coverage, it doesn’t mean you can’t receive the treatment. You can choose to pay out of pocket, explore patient assistance programs, discounts available, and talk to your provider about whether they’re willing to provide the service without going through insurance. Talk with your provider about setting up a payment plan.

Gather Resources.In addition to reviewing the handbook to understand your insurance benefits, explore additional resources. The internet is a helpful source where you can search in more depth to help explore coverage for specific products such as a medicine or procedure. For more information about getting coverage of obesity treatments, click here.

Getting coverage for the best treatments available often requires the three P’s: patience, persistence and paperwork. Remember your weight is not your fault. You deserve the best care possible and it’s worth the extra time and effort to ensure that you receive it.

Here’s obesity expert Dr. Sean Wharton on how important it is to advocate for yourself: