Will My Insurance Cover My Weight Loss Surgery?

Obesity is a continuing epidemic in the United States with over 75% of all adults outside of the range of a healthy BMI (body mass index). When an individual reaches BMI levels in the range of obesity, it is significantly harder for them to lose weight on their own. This is especially true if they have had this high BMI for several years.

Bariatric surgery can help these individuals with weight loss when they also make some necessary lifestyle changes. Bariatric surgeries work by restricting the amount of food an individual can eat and many also block the body’s ability to absorb all the nutrients and calories that are ingested. Most patients lose a significant amount of weight after undergoing bariatric surgery.

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How Am I Going To Afford Weight Loss Surgery?

If your health is suffering and you need bariatric surgery, there is a chance that your insurance company will cover some types of bariatric surgery. Since the inception of The Affordable Care Act, almost one-half of the U.S. states are required to cover weight loss surgery. The state of Georgia is not included in this list but falls under a 1999 Federal law that mandates coverage for morbid obesity.

First Steps To Navigating The Weight Loss Insurance Maze

The first step you should take is to read your policy and find out which procedures your insurance company covers and what you must do to qualify for the procedure. Most patients can access the details of their plan online and/or call the insurance company’s toll-free number if they have questions.

The next step is to find a bariatric surgeon who accepts your insurance and set up a consultation. The surgeon’s office should have a person who handles the insurance paperwork and this person should become your best buddy! Unless you have an obscure insurance company, chances are they have worked with this company previously and will at least have a basic understanding of the inner workings of that insurance company (at least when it comes to bariatric surgery coverage)

Every insurance company will have requirements that you must meet to qualify for coverage. One of these requirements may be that you have tried and failed to lose weight through other methods. These attempts must be documented. The forms of documentation required will vary by an insurance company and may include:

  • Gym Memberships;
  • Jenny Craig Memberships;
  • Structured Weight Watchers Program;
  • Weight Loss Journals;
  • Food Journals;
  • Previous medically supervised weight loss diets;
  • Nutritionist Visits.

Weight Loss Surgery and Insurance Coverage

According to The American Society for Metabolic & Bariatric Surgery (ASMBS), the average cost for bariatric surgery runs anywhere between $17.000 and $26,000 but the exact cost will be dependent on the type of surgery you have, your overall health, and current BMI, and if you encounter any complications, etc.

There is much evidence to support that the cost of surgery is much less than treating the associated obesity-related conditions long-term. Most insurance companies will cover gastric sleeve surgery but not the less expensive non-surgical options such as a gastric balloon or endoscopic sleeve gastroplasty.

Endoscopic sleeve gastroplasty has a proven track record of delivering results comparable to gastric sleeve surgery. It does not require surgery, it is less expensive, has fewer complications, and offers a faster recovery. This FDA-approved weight loss procedure is gaining popularity and has proven to result in significant weight loss.

Even with the supporting evidence and FDA approval, insurance companies do not yet cover non-surgical EGS and currently only cover expensive surgery. Insurance companies in general are slow to cover new procedures, but most bariatric surgeons feel that endoscopic sleeve gastroplasty will be covered by insurance companies in the future because it would benefit all parties.

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What Insurance Companies Cover Weight Loss Surgery

This is a tough question to answer for a few reasons including:

  1. Within insurance companies, there are several different plans available. One plan may cover bariatric surgery and others may not. Make sure you pay attention to all the details when choosing a plan;
  2. Plan and coverage details can change from year to year and even if you continue with the same plan, your premium may go up or they may change certain aspects of the coverage.

Patients face many challenges when attempting to navigate their way through all the confusing insurance requirements, qualifications, documentation, etc. We found this handy tool for checking insurance coverage online from bariatric-surgery-source. Use this tool as a guideline and always check with your insurance company about the details of your specific plan.

If you are planning to have bariatric surgery and your insurance carrier does not currently offer this coverage, if possible, make a plan to switch companies during the open enrollment period. In the interim, begin working on the prerequisites required by your chosen insurance plan and gathering the required documentation.

Does Medicaid Cover Weight Loss Surgery?

Most Medicaid plans do cover some bariatric surgeries including gastric bypass, gastric sleeve, and gastric lap band surgery. They have a qualifying process like other insurance companies but will also treat adolescents. The challenge may be finding a bariatric surgeon that accepts Medicaid as their reimbursement rate to doctors is usually lower than other forms of medical insurance.

Does Blue Cross Blue Shield Cover Weight Loss Surgery?

Some Blue Cross Blue Shield plans do cover bariatric surgery but you should check your plan for exact coverage. Here is an example of what BCBS requires and covers for bariatric surgery.

Requirements to qualify for surgery include:

  1. Must be 18+;
  2. Must have a doctor’s diagnosis of morbid obesity which includes; a Body Mass Index (BMI) of 40+ or 35+ and have a weight-related illness such as:
      • hypertension;
      • sleep apnea;
      • type 2 diabetes;
      • a cardiopulmonary condition, or
      • other serious medical condition that is life-threatening and weight induced.
  3. Patients must also have gone through a structured diet program within 2 years preceding the request for the surgery. Qualifying programs would include or be similar to one structured diet program such as Jenny Craig or Weight Watchers for 6 consecutive months or two 3-month such programs that are completed and non-concurrent.
  4. Patients must also undergo a psychological exam which is completed to determine if the patient understands and is committed to actively implementing and following the lifestyle changes necessary to achieve weight loss and maintain it after this type of surgery.

This Blue Cross Blue Shield Plan Covers These Bariatric Surgeries:

The Policy States It Does Not Cover:

  • Gastric balloon;
  • Biliopancreatic bypass without duodenal switch;
  • Mini gastric bypass surgery;
  • Jejunoileal bypass;
  • Gastric wrapping;
  • AspireAssist;
  • Transoral gastroplasty (StomaphyX).

What Can I Do If Weight Loss Surgery Isn’t Covered By My Insurance?

If you want to pursue bariatric surgery but do not have insurance there are some things you can consider.

  • Most bariatric surgeons offer flexible financing plans;
  • You can work closely with your primary care physician to get many of the medical tests that are needed before undergoing bariatric surgery covered by your health insurance. This may seem a bit covert but it is ethical. Many of the tests that the bariatric surgeon will need are routine tests that are done for many other reasons so if your primary doctor submits them to the insurance company using general CCP codes and they are not coded for weight loss, many of them may be covered. There are many reasons a doctor would order tests such as:
      • Cardiology exam;
      • Psychological exam;
      • Medically supervised diet program;
      • Lab work;
      • Sleep study.

The bottom line: If you are suffering from obesity and desire to have weight loss surgery and rely on medical insurance to cover some or all of it, there are things that you can begin to do now so you meet their qualifications.

Start with your primary care physician and a bariatric surgeon to create an individualized plan and then begin to tackle some of the things on your insurance plan’s qualification list.

Weight loss surgery can be a significant financial challenge but do not let that stop you from pursuing this possible life-saving procedure.

To learn more about bariatric surgery, contact IBI Healthcare Institute today and set up a consultation. Let us share details about the weight loss procedure options that may be best for you.

During your consultation, our dedicated staff will discuss the cost of your surgery and share the flexible financing options we offer. You can also attend our online bariatric seminar to learn more about bariatric surgery and the non-surgical alternatives available.

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