If You Are Covered By Medicare Or Medicaid
Medicare and Medicaid BOTH cover bariatric surgery as long as you meet their qualification guidelines:
To get approved, youll need to be referred by your primary care physician or other attending doctor . Your surgeon will also need to be in The Centers for Medicare and Medicaid Services directory.
Medicaid Coverage & Bariatric Surgeons
Many surgeons do not accept Medicaid due to lower reimbursement levels .
Contact your local surgeon to confirm whether they will accept your Medicaid insurance. If they dont, ask for a referral to a surgeon who does.
If you have Medicare Advantage, youll need to verify that your chosen surgical team and their hospital are in your insurance companys network. Contact your insurance company directly to find out .
See our Medicaid/Medicare Bariatric Surgery page for more information.
Weight Loss Surgery Insurance Secrets
When you have made the big decision to achieve permanent freedom from obesity, nothing should come in your way to qualify for weight loss surgery insurance. However, in reality, many patients experience challenges in getting approvals or face claim denials from their insurers. Here are five proven weight loss surgery insurance secrets that will help you obtain approval for maximum coverage from your insurance company.
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A Discussion Of Your Insurance Options
At some point, after you have spent a considerable amount of time exploring the option of weight loss surgery, you will need to determine how to pay for the procedure. A growing number of states have passed legislation that requires insurance companies to provide benefits for weight loss surgery for patients that meet the National Institutes of Health surgical criteria. And while insurance coverage for weight loss surgery is widespread, it often requires a lengthy and complicated approval process. The best chance for obtaining approval for insurance coverage comes from working together with your surgeon and other experts.
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Bariatric Surgery Is A Special Procedure Performed To Help Overweight And Obese People Combat Weight
The national obesity rate for the USA continues to rise, crossing the 40 per cent mark for adult obesity in 2020. With an increase in obesity comes an increase in surgeries and methods to combat it. Even if you are not at risk, you may want to know if bariatric surgery is an option available for a loved one via their insurance provider. And if not, what other options do you have?
Find Out The Requirements For Weight Loss Surgery Insurance Coverage
Most insurance companies have the following requirements for coverage:
- You must be over the age of 18. If youre asking about an adolescent, make sure to contact your insurance provider.
- BMI over 40 OR BMI over 35 with a weight-related condition such as type 2 diabetes or hypertension
- You must have been morbidly obese for a specific period of time before surgery
- You must have documentation of weight loss attempts using diet and exercise in the past
- You must pass a psych evaluation
Other requirements may include:
- No evidence of substance abuse
- No smoking, or if you are a smoker, you must undergo a smoking cessation program before surgery
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What Can I Do To Ensure Approval
Before your consultation, youll be given a patient health history questionnaire. Its important to fill this out truthfully and completely because it will be translated into your medical record, which will be reviewed by the insurance company.
If you have any documentation of your previous attempts at weight loss whether by diet, exercise or medical supervision, bring a copy to be reviewed and scanned into your chart.
If youve had a previous weight loss procedure, you should obtain copies of your operative report as well as pre- and post-op visits to demonstrate your committed follow-up and compliance with any recommendations that were made by your former provider.
The single most important thing that every patient should do to ensure the likelihood of approval by their insurance company is to remain in full compliance with the requirements set forth in the medical policy . Medically supervised diets often must occur in consecutive months and should be spaced out by approximately 30 days. Failure to keep scheduled appointments in consecutive calendar months will often result in denial and may delay surgery or cause you to have to re-start the prescribed program from the beginning.
The MultiCare Center for Weight Loss & Wellness supports you before, during and after the weight loss journey.
Is Bariatric Surgery Covered By Insurance
If you are researching bariatric surgery, you are no doubt already envisioning your life after the procedure. From greater energy to an enhanced body image after weight loss, there is a lot to look forward to. But before you can enjoy the advantages of surgery, you have to figure out how to afford your bariatric procedure of choice.
Weight loss surgery costs vary between types of procedures, providers, and geographic locations. However, in every case, procedures cost more than pocket change. This leads to many wondering if bariatric surgery is covered by insurance.
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Procedures That Are Not Covered
The following procedures are NOT covered by Aetna:
- Band over bypass or LASGB revision of prior Roux-en-Y gastric bypass
- Band over sleeve or LASGB revision of prior sleeve gastrectomy
- Bariatric surgery as a treatment for infertility
- Bariatric surgery as a treatment for type-2 diabetes in persons with a BMI less than 35
- Gastric bypass as a treatment for gastroparesis
- Laparoscopic gastric plication , with or without gastric banding
- Loop gastric bypass
- Natural orifice transoral endoscopic surgery
- Open adjustable gastric banding
- Roux-en-Y gastric bypass as a treatment for gastroesophageal reflux in non-obese persons
- Sclerotherapy for the treatment of dilated gastrojejunostomy following bariatric surgery
- Silastic ring vertical gastric bypass
- General Appeal Instructions
- Appeal Details Specific to Aetna
If Aetna denies your weight loss surgery claim and you think it should be covered, consider filing an appeal.
Clinical Care Teams Committed To You
When you request an appointment with our program, our clinical care team will gather your insurance information and give your insurance company a call to find out your specific bariatric insurance coverage and benefits.
Your clinical navigator will then provide you with all the information you need to make an informed financial decision, as well as provide you with self pay and financing options if requested.
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Self Payment Options For Bariatric Surgery
If your appeal is continuously denied, you may consider the options of paying for the surgery by yourself. You can ask friends and family to help you with the cost and take small loans from them. You may also consider fundraising for your cause. You can use a website to fundraise or hold a games event or bake sale to raise the funds. You may also check to see if you are eligible to receive tax refunds or money from your retirement funds. You may also use credit cards with 0 per cent APR with no interest for the first 12 to 24 months.
Should I Pay In Cash Or Use Insurance
When considering getting a bariatric procedure done, insurance is the ideal way to go. However, whether you should pay out of pocket or through insurance will depend on the type of policy you have. Today, most major insurance carriers cover laparoscopic gastric bypass, gastric sleeves, and lap band surgeries. However, that does not mean your health plan also provides coverage for such procedures.
While some plans entirely exclude bariatric surgery, others may require you to pay more to include coverage for weight loss procedures, Read your individual health policy carefully or ask your agent to know whats covered and whats not.
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If Your Insurance Is Through Work: Large Group
If you get your insurance through your work and your employer has 51 or more full time employees, it is completely up to your company to decide whether or not to cover weight loss surgery.
To confirm your coverage, you have a three options:
- Option 1 : Your local surgeon will contact your insurance company to confirm your benefits for free. Their office will be very familiar with your insurance companys requirements and approval process, so its usually a good idea to let them do the leg work for you. .
- Option 2: Ask your Human Resources Department whether or not weight loss surgery is an included benefit under your plan.
- Option 3: Contact your insurance company yourself and/or check your Summary Plan Description . for the full list of United States insurance companies, contact information and bariatric surgery coverage policy details.
If you find out that bariatric surgery insurance is NOT included under your plan, you may want to head over to our Weight Loss Surgery Insurance Secrets page to learn how you may be able to get your company to add the coverage.
If you have short term disability insurance through your employer, you may be able to receive portion of your monthly salary while youre having and recovering from surgery. See our Short Term Disability section for more information.
How Does Obesity Affect Health Insurance
About 19% of children and 42% of adults are obese, according to the Centers for Disease Control and Prevention. Obesity has been tied to many health conditions, including:
- Some types of cancer
All told, obesity costs the health system $147 billion a year, the CDC says.
A 2018 study published in the Journal of Obesity & Weight Loss found that the average percentage of expenditures for health care related to obesity during the years 2010 through 2015 was:
- 9.21% for commercial insurance
- 4.74% for patient out-of-pocket spending
Given all these costs, can health insurance companies charge you higher premiums if youre obese?
Health insurance companies canât charge you more, but your employer can, Stegemann says.
For instance, some companies will create a program that basically taxes you for certain bad habits, he says. You might pay more for health insurance if youre a smoker or if you are obese.
Such programs arent common, but theyre becoming more so, Stegemann says. We are hearing of more and more of it over the last five years, he says.
Stegemann believes employers have the right aim in mind, but theyre going about it the wrong way.
They basically are wanting you to be healthy, but they donât give you the tools to do it, he says, adding that many plans dont cover you for things like obesity medications or surgery or even a gym membership.
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How Much Does Gastric Sleeve Surgery Cost
According to one research, it takes an average of three years from the time you contemplate gastric surgery to the time you actually get it. You may spend many hours studying, reading, and speaking with post-operative patients regarding their procedures.
But, how much is gastric sleeve surgery? A Gastric sleeve surgery costs an average of $23,000, while a gastric bypass surgery costs $14,500, and sleeve gastrectomy surgery costs $14,900. So, before you get too excited, find out if your insurance will cover weight reduction surgery or not.
Patients belonging to the middle to upper classes are the majority of people who undergo this surgery. In addition, most people considering weight reduction surgery may not afford to pay the $20,000 gastric sleeve cost to reduce weight.
However, insurance companies are also beginning to pay weight reduction surgery amounts in more significant numbers than ever before. So, if you are determined to get this even after knowing how much is gastric sleeve surgery, talk to your insurance provider.
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Anthem Weight Loss Surgery How To Avoid A Denial
Your Anthem Blue Cross Blue Shield weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.
First, try our insurance tool to quickly check your insurance coverage:
Read and click below for additional weight loss surgery insurance details.
- 35+ Body Mass Index
- Documentation of failed diet attempts
- Psychological evaluation
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Past Attempted Weight Loss
In most cases, insurance companies require that your patient has made sufficient efforts to lose weight before theyll approve coverage for bariatric surgery. This can include completing a medically supervised weight-loss plan developed by the insurance provider or making other efforts to lose weight as recommended by a doctor. Generally, insurers require the program or efforts to last from three to seven consecutive months.
If your patient has been unsuccessful in their weight-loss efforts after this period, they may then be considered a candidate for bariatric surgery. You will likely need to provide documentation of the attempts to lose weight, including dietary and exercise regimens, to gain insurance approval.
Gastric Sleeve Insurance Coverage: Action Points
Many private insurers will require a “letter of medical necessity” from a surgeon before they agree to pay for your gastric sleeve surgery. The letter should include information on your height, weight history and BMI, a detailed description of your obesity-related health conditions, your current medications and a detailed description of how obesity affects your daily activities.
Be proactive where you can. Start collecting letters and documentation from all health care professionals who have treated you for obesity-related problems now. Keep detailed records of all your weight loss attempts.
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How To Get Insurance To Pay For Bariatric Surgery By Demonstrating Medical Necessity
Most insurance plans require that medical necessity be demonstrated before coverage is granted for weight-loss surgery. This means that in addition to your consultation with them, youll need to provide evidence that bariatric surgery is necessary for each patient. The exact criteria vary from one insurance provider to the next but typically include the following.
Bariatric Insurance Pricing And Financing
Well work with you to put weight-loss surgery at OHSU within reach.
- If you have health care insurance, we can help you seek authorization for bariatric treatment.
- If you dont have insurance, call our scheduling coordinator at to learn about other options.
- We offer some of the lowest pricing in Oregon.
- We can direct you to a financing option.
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If Your Policy Does Not Cover It: Seek Partial Coverage
You may be able to get part of the costs paid for by insurance even if weight loss surgery isnt covered. Its all about how your doctor and hospital submit your claims to your insurance company.
For example, there are many non-bariatric surgery reasons for your doctor to recommend:
- Cardiology exam
- Psychological exam
These are ordered for many reasons other than bariatric surgery and may be covered as a result. If your doctor submits one of these claims using a weight loss surgery CPT code , your insurance is unlikely to cover it. But if your doctor uses a general CPT code, it probably will be covered.
While this may sound sneaky, it is an ethical practice. After all, these tests will be beneficial regardless of whether you move forward with surgery.
What Are The Qualifications For Bariatric Surgery
If you have a BMI of 40 or more and are at risk for health problems, you may qualify for bariatric surgery. If you have a BMI 35-40, some insurance companies may qualify you if you have 1-2 comorbidities such as being diagnosed with high blood pressure, diabetes, obstructive sleep apnea, and/or cardiovascular disease. Insurance will not cover bariatric surgery for an individual with a BMI of 35 without comorbidities. This does not mean you are not qualified for weight loss surgery per se, it only means the insurance wont pay. Many surgeons globally believe that an individual with a BMI of 35 will greatly benefit from weight loss surgery and be able to have very successful outcomes and enjoy a healthy and fulfilled life long term. Many bariatric clinics have a financial program that will help you budget and manage the cost comfortably. Care Credit is another financial option to pay for weight loss surgery. The application is easy and straightforward.
Bariatric surgery is a life-changing procedure that can help you achieve your weight loss goals. If you are considering bariatric surgery, be sure to check with your insurance provider to see what is covered under your policy. You can also contact a bariatric surgery center to learn more about the procedure and to find out if you are a candidate. With careful planning, you can ensure that you have the coverage you need to pay for your procedure and get the care you deserve.
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Weight Loss Surgery For Medicare Plans
All Medicare plans are required to cover the following weight loss surgery procedures:
- Duodenal Switch
- Vertical Banded Gastroplasty
Please see below for the procedures Anthem Blue Cross Blue Shield covers, might cover under certain circumstances, and those that are not covered under any circumstances:
Bariatric Surgery Insurance Coverage
Even though most healthcare companies cover bariatric procedures bariatric surgery insurance coverage will depend if there is a bariatric surgery benefit on the specific health care plan.
In regards to bariatric surgery health insurance plan coverage we strongly encourage our patients to call their health insurance providers and verify:
- whether bariatric surgery is covered by your health insurance plan policy
- what percentage of the facility and physicians bill will be patients responsibility
Our practice currently accepts the following insurance plans:
If you do not see your insurance plan on the list, please, call us we most likely accept it. Bariatric surgery insurance coverage requirements sometimes are hard to understand. Please dont hesitate call the office and our Insurance Specialist will gladly help you to verify your benefits.
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