How to Appeal a Surgery Denial: Bariatric, MRI & Hospital Stay
Had your surgery or procedure denied? According to the American Society for Metabolic and Bariatric Surgery, approximately 25% of bariatric surgery patients face multiple denials before approval. This guide shows you how to appeal and get the care you need.
Key Statistics: Surgery and Procedure Denials
- ~25% face multiple denials — Bariatric surgery patients before approval (ASMBS)
- 60% report worsening health — During the appeals process (ASMBS)
- 6-12 months required — Typical supervised weight loss before bariatric approval (CMS NCD 100.1)
- 60-80% of external reviews — Overturn surgery denials (HealthCare.gov)
Common Surgery and Procedure Denials
Bariatric Surgery (Weight Loss Surgery)
According to CMS NCD 100.1, Medicare covers bariatric surgery for morbid obesity with comorbidities. Commercial insurers typically require:
- BMI ≥35 with obesity-related conditions (diabetes, hypertension, sleep apnea) OR BMI ≥40
- Documented 5-year weight history showing morbid obesity
- 6-12 months of physician-supervised weight loss attempts
- Psychological evaluation and clearance
- Medical records proving obesity-related comorbidities
MRI and Advanced Imaging
MRIs are commonly denied for perceived lack of medical necessity. Insurers often require:
- Prior conservative treatment (physical therapy, medications, X-rays)
- Clinical documentation supporting the diagnosis
- Pre-approved imaging facility (in-network)
- Specific clinical criteria for the body part being imaged
Inpatient Hospital Stays
Hospital stays are denied when insurers argue outpatient or observation care would suffice. Common issues:
- Downgraded from inpatient to observation status
- Length of stay deemed excessive
- Condition not meeting inpatient criteria
- Missing documentation of clinical severity
Why Surgery and Procedure Claims Get Denied
Not Medically Necessary
The insurer's clinical guidelines don't support the procedure. Counter with physician letters, clinical studies, and medical society guidelines.
Policy Exclusions
Some plans exclude certain surgeries (cosmetic, weight loss, experimental). Check your plan documents carefully.
Incomplete Pre-Authorization
Missing documentation, required evaluations, or supervised treatment period not completed. Ensure all requirements are met.
Out-of-Network Facility
Surgery scheduled at non-network hospital. May be overturned if no in-network option exists.
Experimental/Investigational
Newer procedures may be labeled experimental. Cite FDA approvals and clinical evidence in appeals.
Step-by-Step: How to Appeal a Surgery Denial
Review the Denial Reason
Read your denial letter carefully. Request the insurer's specific clinical criteria and coverage policy for your procedure. You have the right to this information.
Gather Complete Documentation
Collect all medical records, test results, specialist evaluations, and treatment history. For bariatric surgery, include your 5-year weight history, supervised diet records, and psychological evaluation.
Get Multiple Physician Letters
According to the ASMBS, letters from your PCP plus specialists (endocrinologist, cardiologist, sleep specialist) significantly improve approval odds.
Request Peer-to-Peer Review
Your surgeon can request a direct conversation with the insurer's medical director. This often clarifies requirements and can lead to approval without a formal appeal.
Submit Formal Appeal with Guidelines
Include letters of medical necessity, cite CMS criteria, medical society guidelines, and all supporting documentation. Reference why you meet the insurer's own criteria.
Sample Surgery Appeal Letter
Frequently Asked Questions: Surgery Denials
How often is bariatric surgery denied?
According to the ASMBS, approximately 25% of patients face multiple denials before approval. Many denials are overturned on appeal with complete documentation.
Does Medicare cover bariatric surgery?
Yes. According to CMS NCD 100.1, Medicare covers bariatric surgery for morbid obesity with comorbidities at certified centers. Surgery solely for weight loss is not covered.
What if my plan excludes the surgery?
If your plan explicitly excludes the procedure, appeals typically won't work for coverage. However, check if the exclusion applies to your specific situation (e.g., surgery for medical necessity vs. cosmetic purposes may differ).
What is a peer-to-peer review?
A peer-to-peer review is when your surgeon speaks directly with the insurance company's medical director to discuss the clinical necessity of your procedure. This often resolves denials quickly.
Related Appeal Guides
About This Guide
This guide is provided for educational purposes only and does not constitute medical or legal advice. Statistics cited are from publicly available sources including ASMBS, CMS, and AHRQ.
Always work with your healthcare provider when appealing surgery denials.