Bariatric Surgery Insurance

If you have health insurance and are considering bariatric surgery, you will want to find out if your insurance plan covers bariatric surgery. Although many insurance companies cover the cost of bariatric surgery when it is considered a medical necessity, some health plans have an outright exclusion. Also, as coverage varies between insurance companies and health plans, it is important to contact the insurance company as soon as possible to find out if bariatric surgery is a covered benefit on your specific plan, requirements for coverage, and patient criteria.

Insurance Coverage for Bariatric Surgery

Bariatric Surgery Insurance

Just because your health insurance covers bariatric surgery, coverage is not automatic. Most insurance companies have certain requirements that must be met before pre-approval authorization is given. The process may be quick and straight forward for some, but for others that process may be long and frustrating.

Factors that insurance companies consider when determining coverage approval include:

  • Patient Criteria
  • Medical Necessity
  • Weight Loss Attempts

If your bariatric surgery is covered, you will still be responsible for any co-pay, deductible, and co-insurance amounts per your policy limits.

Insurance and Choosing A Bariatric Surgeon

Even if your insurance covers bariatric surgery, it is important to choose a surgeon that is covered under your health plan. It is common for health plans to have a list of preferred providers that have agreed to accept the terms of coverage. Check the list provided by your health plan and choose a bariatric surgeon that accepts your health insurance.

Meeting Patient Criteria for Insurance Coverage

An insurance company will look to see whether or not the individual meets the criteria for bariatric surgery based on age, weight, body mass index (BMI), and obesity related health conditions. Many insurance companies will use the patient guidelines for bariatric surgery set by the National Institute of Health (NIH), which include:

  • BMI is greater than 40 (morbidly obese), or BMI is greater than 35 (obese) with co-morbidities such as heart disease, diabetes, high blood pressure, sleep apnea, or degenerative arthritis
  • Five year history of obesity
  • Failure to lose weight with non-surgical methods
  • High risk for obesity-associated morbidity or mortality
  • Acceptable operative risk
  • Willingness to comply with lifetime dietary requirements

Medical Necessity

Most insurance companies require a Letter of Medical Necessity from your bariatric surgeon stating why weight loss surgery is necessary. The letter will usually include information about your weight, BMI, obesity history, health history, weight loss history and the doctor’s conclusion that bariatric surgery is medically necessary.

Weight Loss Attempts

Bariatric surgery is an expensive and serious operation and insurance approval will usually be considered only if a patient has made serious attempts to lose weight without surgery. Insurance companies will commonly request documentation of previous weight loss attempts to verify that all other options have been exhausted.

Requested documentation of previous weight loss attempts include items such as:

  • Medically supervised weight loss programs
  • Enrollment in weight loss centers (Weight Watchers, Jenny Craig, NutriSystem)
  • Diet plans (Atkins, Zone, South Beach)

Some insurance companies will request a six month weight loss history, while other insurance companies will require a one to two year history. Some insurance companies may also specifically require participation in a medical weight loss program under doctor supervision.

Reasons Prospective Patients Do Not Have Bariatric Surgery

Bariatric Surgery Denials Graph
Source: American Society for Metabolic & Bariatric Surgery (Study AH10)

Covered Bariatric Procedures

Insurance coverage for bariatric surgery can vary based on the specific bariatric procedure. Gastric bypass surgery is the most commonly covered bariatric procedure because it has been performed for so many years and has been shown to be a very effective treatment for obesity as well as many metabolic conditions. Gastric band surgery was once considered experimental and investigational, but is now considered a legitimate bariatric procedure as well and covered by many insurance companies, including Medicare. Duodenal switch is still not covered by most insurance companies.

Handling Insurance Denials

If you submit an insurance request for bariatric surgery and receive a denial, it may still be possible to get approval through the appeals process. When you get a denial, contact the insurance company to find out the specific reasons why coverage was not approved. Often, the first denial is due to issues which can be worked out, such as lack of weight loss documentation or appropriate medical information.

Many bariatric patients have been successful in gaining coverage for bariatric surgery by appealing the denial and then working to satisfy the insurance requirements. While it is important to be personally involved and persistent with the insurance company, it is also helpful to have your doctor assist you in getting insurance approval.