Obesity is a medical condition that ranks among the most widespread health problems in today’s society. It affects individuals of all age groups and makes their health susceptible to a great deal of adverse effects. However, within the scope of insurance claims, people are asking: Can obesity be used as a primary diagnosis on a claim? This article simplifies working with obesity as a primary diagnosis for insurance payment processing and gives ways of increasing the acceptance of claims for obese people.
What Does It Mean to Use Obesity as a Primary Diagnosis?
Primary diagnosis refers to the condition determined by the provider that necessitates treatment. To illustrate the primary diagnosis for obesity, the diagnosis does not include any other complaints such as diabetes, heart problems, et al., but rather the simple condition of obesity.
The World Health Organization and the American Medical Association consider obesity to be a chronic illness. It is based on measuring an individual’s body mass index as weight per unit height. According to the following application of BMI, here is obesity:
- Overweight: BMI of 25–29.9.
- Obesity: BMI of 30 or higher.
- Severe obesity: BMI of 40 or higher.
Despite this classification, insurers don’t always treat obesity as a stand-alone disease. Many see it as a lifestyle issue and focus instead on treating the complications it causes.
Medical Coding for Obesity
All insurance claims are processed under a uniform relevant system known as the International Classification of Diseases, 10th Revision (ICD-10). Obesity in this categorization is placed under “E66,” inclusive of the following:
- E66.0: Obesity due to excessive caloric intake.
- E66.01: Extreme obesity with hypoventilation syndrome.
- E66.9: Obesity, like other conditions, is unspecified.
These codes are utilized by physicians to describe obesity in people’s files and in the submission of claims. Such codes are examined by insurers for purposes of coverage approval. In addition, the particular policy offered and the perspective of the insurer with regard to any claims made on the basis of obesity will determine the result.
Can Obesity Be Used As A Primary Diagnosis On A Claim
Claims, especially those risked in as much as obesity is considered the focal diagnosis in a claim, do not come easy. Here’s why:
- The Social and Medical Biases
Some health insurance companies regard obesity as a normal behavioral attitude and not a health issue. Such attitudes tend to make some kinds of treatments, such as those concerned with obesity, not covered by the insurance policy.
2. Insurance Constraints
Most insurance policies do not cover the treatment of obesity unless it occurs with other diseases such as diabetes, hypertension, etc. Even specific kinds of treatments, such as weight loss surgery or drugs, may be completely omitted.
3. Lack of Substantiation for Medical Necessity
There are instances when insurers will want to see certain levels of treatment documentation in particular clinical situations before considering treatment for obesity for purposes of health improvement. Failing this, claims are sometimes lost.
In what instances is obesity considered a primary diagnosis?
Nonetheless, there are conditions under which there are ‘limitations’ on the severity of obesity:
Pre-approval for bariatric surgery
Most insurance policies will pay for weight loss surgery provided. For more severe cases of obesity (BMI 40 and above or 35 and above with comorbidities), most insurance policies will pay for it. Some insurance companies may look for evidence of treatment of obesity before they authorize surgery.
Weight Loss Programs with Behavior Modifications
A few of them cover therapeutic sessions designed to change eating habits and increase physical activities without restriction to obesity only.
Weight Loss Drugs
Medicines such as Wegovy or Saxenda may be approved for the treatment of obesity when the patient is under a doctor’s care for prescriptions.
Usually, these situations have additional requirements, namely treatment plans based on documentation of medical necessity, which means a failure to treat the patient would be detrimental to their health as evidenced by your physician.
Common Treatments for Obesity and Their Coverage
The types of obesity treatments covered by insurance can vary, but here are the most common options:
1. Behavioural Therapy
Focus: efficacy strategies that encourage clients to exercise more and practice a healthy diet.
Coverage: Usually not applicable unless it concerns, for instance, obesity or hypertensive clients.
Medications
Focus: pharmacological treatment of overweight and obesity.
Coverage: Some health policies provide a cover for these drugs, but the majority of them are prior authorized.
2. Bariatric Surgery
Focus: Gastric restriction to reduce food intake.
Coverage: Has been received by a majority of the health insurance under certain criteria (e.g., BMI more than 40 or BMI more than 35 with co-morbid conditions such as diabetes).
3. Nutritional Counseling
Focus: Prescribed diets encouraging other than medical weight loss.
Coverage: Often necessitates a referral from a medical professional.
Primary diagnosis vs. secondary diagnosis
In health insurance practice, it is common to include more than one claim in the insurance policy for specific treatment procedures. These are differentiated as;
Primary Diagnosis: The main disease under treatment
Secondary Diagnosis: Other diseases that justify the need for treatment.
It is common to mention obesity as a secondary diagnosis to further fortify the claim. For instance:
Primary Diagnosis: Diabetes Mellitus II
Secondary Diagnosis: Obesity
This technique indicates how obesity is affecting or exacerbating another condition, thereby making its treatment more justifiable.
Employer and private insurance policies on obesity
Insurance policies can differ significantly depending on who provides them.
Employer-Provided Insurance
Often, the extent of coverage will vary according to what type of plan an employer picks.
Some plans for health insurance may omit treatments for obesity unless they are associated with any other illnesses.
Private Insurance
These policies are different in many ways. Some policies include obesity treatments in the list of services, while others do not.
More comprehensive plans are more likely to be approved if the primary diagnosis is obesity.
Read also: Is Functional Heartburn Related to Obesity?
How to Improve the Chances of Claim Approval
When you are going to submit the obesity treatment claim, there are some recommendations on how to increase the success rate of your claim:
- Document Thoroughly: Maintain all medical reports, notes by the doctors, laboratory tests, and treatment strategies.
- Use the right ICD-10 codes: Your healthcare provider should use obesity-related codes.
3. Highlight relevant conditions: Include any complications you may have, such as sleep apnea, diabetes, and others, in your claim.
4. Appeal Denials: When a claim is filed and the answer is negative, do not lose hope. Request for the negative and make the necessary additions for the grant of the claim.
Upcoming Changes in the Area of Claims for Obesity
Insurers have started addressing the issue of obesity in their cover policies differently. A growing number of insurance firms are classifying obesity as an ailment of medical concern. This is expected to result in:
- More optimistic coverage for loss weight enhancement products.
- More consistent claims are that obesity is not a way of life.
- More drugs as well as treatment types are available.
FAQs About Obesity Claims
- Can a person claim insurance as a result of obesity alone?
Possibly, yes, but it is under your policy. Some insurance companies will allow obesity‘s the primary diagnosis, while others will demand other associated conditions like diabetes, heart disease, etc.
- What are the obesity treatments that can be covered most of the time?
Bariatric operation.
Saxenda and other similarly prescribed drugs.
Dietary advice.
Counselling.
- What should I do now that my request for obesity treatment was turned down?
Ask the insurance provider to provide further details on the denial in writing.
Look for other evidence that might help your case, such as a physician’s report on the need for medical intervention.
Go ahead and request reconsideration of your health insurance plan.
- Is there any difference in the coverage for obesity among different regions?
Yes. For instance, there are some countries that have developed insurance systems that provide treatment for obesity as a disease on its own while others only treat comorbid statuses.
- Where can I check if my insurance covers treatments for obesity?
Call the insurance company and inquire separately about any services related to obesity, such as medications, counseling, or other forms of surgery.
Conclusion
Indeed, as it is a health problem of a complex nature, arguing it as a first diagnosis on a complaint may not be satisfying. This will prove in turn beneficial, as you will be able to know where the obstacles in the process arise, how overweightness is perceived by the insurers, and how the procedure is explained here.
Leave a Reply