When Does Insurance Cover Weight Loss Surgery?

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Posted: October 15th, 2020
Overweight women at nutritionist's office

Thinking about bariatric surgery to lose weight? Don’t let questions about insurance coverage stop you.

 

If you’ve tried unsuccessfully to lose weight, you may be considering weight loss surgery. This life-changing procedure could add years to your life and prevent serious health conditions. But does insurance cover the procedure? 

Most insurance companies do cover bariatric surgery, although you’ll have to meet some health-related criteria before approval is granted. A weight-loss specialist and your primary care doctor will work with you and your insurance provider so you can undergo the procedure and get on the path to better health.

Guidelines for Bariatric Surgery

Before you visit a bariatric surgeon, first check with your health insurance provider to see if the surgery is covered. Covered services are listed on your insurance provider’s website, or you can ask your employer’s HR person about benefits if you’re covered at work. 

In most instances, the surgery will be paid for by your insurer. But you may have to pay for some out-of-pocket charges such as your deductible, copays, or other co-insurance payments. 

Your doctor’s administrative staff will guide you through the pre-approval process, which includes establishing coverage, your costs, and eligibility for the operation. Each carrier may differ in their exact criteria, but the basic standards needed for weight-loss surgery are:

  • — You must be 18 years of age and have reached your full skeletal growth.

  • — You should have a body mass index (BMI) of 40 or more, which is classified as extreme obesity.

  • — Or you may have a BMI of between 35 and 40 with one or more of the following significant comorbidities: heart disease, severe sleep apnea, type 2 diabetes, and hypertension.

 

Your insurance company may request medical documentation that you have been diagnosed with those conditions over a certain period of time, say, two years. In addition, your insurance carrier may ask that you participate or have participated in a doctor-supervised weight-loss, exercise, or nutritional program for a specified period of time prior to green-lighting the surgery. Your doctor must provide records of your progress through the program and evidence of numerous face-to-face consultations. Popular weight-loss plans such as Weight Watchers and Jenny Craig are not considered medically supervised weight loss programs. 

You may also need referrals or medical evaluations from a physician or bariatric surgeon recommending the operation. The insurer may further request a nutritional profile done by a registered dietitian as well as a mental health assessment. The latter is important because the insurer will want assurance that you will follow through with the pre- and post-op instructions in order to have a good outcome.

Once all the paperwork and certifications are in place, you can schedule your weight-loss operation. Again, each carrier varies in what type of procedures it will approve, but typically gastric bypass and gastric sleeve will be covered by health insurance.

Although the thought of meeting all the eligibility requirements may be daunting, don’t let it deter you from seeking this potentially life-saving operation. Your bariatric team will help you obtain all the necessary approvals, and may even offer financial assistance through various payment options

Considering Weight-Loss Surgery?

If you’re thinking about weight-loss surgery, the staff at Long Island Laparoscopic Doctors will assist you through the process of determining eligibility and obtaining pre-authorization. We also offer many financing plans to ensure the operation is affordable for your budget. Contact us today for a consultation.