Is Endoscopic Sleeve Gastroplasty Covered by Insurance?

Is Endoscopic Sleeve Gastroplasty Covered By Insurance?

One of the biggest health issues that has reached epidemic proportions in the United States today is obesity with over 43% of the adult population classified as obese. Approximately another 30%+ adults are classified as overweight. In 1962 the obesity rate in the United States was 13.2% and in 2016 it had already almost tripled and had risen to 39.8%. We are not on the right track as a nation and something needs to change.

The good news is that individuals who suffer from obesity and desire to become healthier have options. One of these options is bariatric surgery. There are also some newer procedures available to help them lose weight that do not require surgery.

The not-so-good news is that many patients find the financial obligations related to getting the help they need daunting. They need to know answers to questions like whether endoscopic sleeve gastroplasty is covered by insurance or if their insurance will cover a gastric bypass. Today we are going to look at the relationship between obesity and insurance and how to navigate your way through it.

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Does Insurance Cover Weight Loss Surgery?

Some but not all insurance carriers cover some types of weight loss surgery but each company has different requirements and limitations. Even if a patient’s body mass index (BMI) classifies them as morbidly obese, does not necessarily mean their insurance will approve bariatric surgery. Bariatric surgery is not automatically covered for every person by every carrier just because their BMI number is high. According to the Mayo Clinic, individuals who are most often considered candidates for bariatric surgery:

  • Have tried losing weight through diet and exercise but have been unsuccessful;
  • Have a body mass index of 40+;
  • Have a body mass index of at least 35+ and are suffering from obesity-related health issues such as type 2 diabetes, high blood pressure, etc.;
  • These are just the basics of the criteria for determining eligibility for weight loss surgery and individuals will need to check with their insurance companies for specifics.

Why All Insurance Companies Should Cover Bariatric Surgery

Currently, there are 23 states where it is mandated that bariatric surgery be included in ACA-compliant health plans but neither Georgia nor Florida is currently included on the list (this list does not include group insurance or private health plans). Weight loss surgery, as well as non-surgical weight loss procedures, should be covered on insurance plans for many reasons including:

1. Bariatric Surgery Improves Overall Health

The benefits of bariatric surgery have been the subject of much research and have been published through many different outlets. Many patients experience total remission of type 2 diabetes after losing weight as a result of bariatric surgery. Other weight-related illnesses and risks that are reduced after weight loss surgery are:

  • Heart disease and stroke;
  • High blood pressure;
  • Sleep apnea;
  • Cholesterol issues;
  • Asthma and breathing issues;
  • Arthritis & joint problems;
  • GERD (gastroesophageal reflux disease);
  • Fatty liver disease;
  • Some cancers;
  • Urinary incontinence/bladder issues.

2. Reduction In HealthCare Spend

If the instances of obesity were reduced in the United States there would be a significant decrease in the amount of money spent on healthcare.

Each year an estimated $147 billion to over $210 billion in healthcare costs is directly attributed to treating adults with obesity-related illnesses. This chunk of change is equivalent to about 22% of the total of all medical spending in the United States. In addition, childhood obesity-related illnesses make up over $14 billion annually in healthcare spending.

In addition, a 2018 report published by the Milken Institute detailed and categorized the costs of chronic diseases related to the obesity epidemic to the tune of $480.7 billion in direct costs, and $1.24 trillion indirectly from lost productivity. The report went on to state that obesity accounted for over 47%, and was the largest contributor, to the costs related to chronic diseases in the United States.

Bariatric Surgery and Insurance Coverage

There is a fine line between what insurance companies consider necessary for one’s health and elective or cosmetic procedures. They are also notoriously slow to recognize and embrace medical and technological advancements that bring new procedures despite their effectiveness or lower costs.

At this time, most insurance companies that do allow for bariatric surgery will cover gastric bypass surgery, gastric sleeve surgery, and lap-band surgery. Patients need to do their research and find the carriers that cover bariatric surgery and the specifics related to the coverage. Research should include the following steps:

  1. Review the fine details of coverage in the health insurance policy;
  2. Vet and choose a qualified in-network surgeon;
  3. Find out if you are a qualified candidate;
  4. Work with the surgeon to confirm eligibility and coverage with the insurance company

Getting Your Health Insurance To Pay For Weight Loss Surgery

Just because your health insurance policy reflects they cover certain types of bariatric surgery, doesn’t mean it will be easy for you to utilize it.

Be Prepared

Usually obtaining a pre-approval from the insurance company requires a good amount of paperwork. Each company has its own requirements as well as the definition of ‘medically necessary” when considering a patient a qualified candidate.

Most insurance companies require documented proof of medically-supervised weight-loss attempts and do not consider weight watchers or other such programs adequate.

Working with an experienced bariatric surgeon will help you navigate through this process. Most bariatric specialists feel that advocating for their patients is an integral part of the responsibility that comes with being a surgeon and they will work diligently to help you.

It is important to have a good understanding of what your insurance policy covers and expects so you can successfully receive approval.

Be Persistent

According to the American Society of Metabolic and Bariatric Surgery, one of the top reasons that patients do not have bariatric surgery is because they are denied coverage.

Apparently, for about 25% of the patients attempting to utilize their coverage, it is an uphill struggle and they are denied 3 times before obtaining approval.

If your policy states it covers the type of surgery that you are after and you meet the qualifications as a patient, do not give up. You may have to jump through some hoops and go through an appeals process but with the help of your surgeon, you should eventually get approval.

Take the first step on your journey to a healthy life

IBI Healthcare Institute provides an unmatched patient experience and outstanding results. You matter to us.

Why Insurance Should Cover Endoscopic Sleeve Gastroplasty

Currently, insurance plans do not cover endoscopic sleeve gastroplasty (ESG), but they should! ESG has gained notoriety over the past several years for being just as effective as gastric sleeve surgery with fewer complications because there are no incisions. In July 2022 ESG became FDA approved and it is likely that in the future it will be covered by insurance plans. Learn more in the official press release.

Complications from surgery translate into increased medical costs to address the complications. Gastric sleeve surgery has an associated complication rate of 13% which is far higher than the 2% related to endoscopic sleeve gastroplasty (ESG).

Endoscopic Sleeve Gastroplasty Comparison Chart

Bariatric Procedure Hospital Stay Length Average Cost Complication Rate
ESG 0-1 days $10,000 2%
Gastric Sleeve 2-3 days $14,900 13%
Gastric Bypass 2-5 days $23,000 20%
Gastric Lap Band 1-2 days $14,500 33%

Using the chart of approximates above it is easy to conclude that there is a huge opportunity for insurance companies to reduce overall healthcare costs if they cover non-surgical weight loss options like ESG. Not only the difference in endoscopic sleeve gastroplasty costs vs the typically covered bariatric surgeries but also costs related to hospital stays and complications. In addition, the costs related to obesity-related illnesses including prescription drugs would be reduced overall as patients lost weight and became healthier.

Hopefully, in the future patients will not have issues getting non-surgical weight loss covered by insurance.

What Do I Do if My Insurance Does not Cover Bariatric Surgery?

If you want to have a procedure like endoscopic sleeve gastroplasty (ESG) that is currently not covered by health insurance, you do have options.

Most bariatric surgeons work with companies that offer medical loans to help patients finance necessary surgery. IBI Healthcare offers flexible financing options, and some of them require no payments in the first 3-6 months. It may also be possible to offset costs using an FSA or HSA account.

Additional alternatives may include:

  • Changing employers or insurance carriers that offer coverage for bariatric surgery;
  • Begin a medical weight loss program with a bariatric surgery center;
  • The IRS allows certain deductions for weight loss-related costs that you may be eligible to benefit from.

If you are interested in bariatric weight loss or the ESG procedure and would like to learn more about if insurance will cover your bariatric surgery, please contact IBI Healthcare Institute today. During your consultation, the knowledgeable and professional staff can answer your questions about the different weight loss options and create an individualized plan to help you reach your goals.

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