Is Bariatric Surgery Covered By Insurance?

Obesity has surpassed epidemic proportions in the United States and continues to climb. Statistics show that among American adults only 25% are within a healthy weight range. The other 75% have BMI (body mass index) rates that are categorized as overweight or obese. Losing weight without medical intervention is almost impossible for someone who has had a high BMI for years.

Weight loss surgery also called bariatric surgery is an option for patients with a high BMI to lose weight. Bariatric surgery can help patients with portion control and restrict the number of calories their bodies can absorb to promote weight loss. Patients must also adopt and adhere to lifestyle changes which include eating a healthy low-calorie diet and getting the doctor-recommended amount of physical exercise each day.

Can I Buy Insurance To Cover Bariatric Surgery?

Yes, bariatric surgery is an option on many health insurance plans, and most cover some type of bariatric surgery however, qualification for the covered procedures is subject to certain conditions. Each health insurance company has its own criteria or prerequisites that they require before they will approve coverage of your bariatric surgery.

Finding out if bariatric surgery is covered by insurance can be quite confusing because one insurance company usually offers several different medical plans within their organization. Each plan may offer coverage for different procedures or no coverage depending on which one you choose. It is important that you carefully compare policies to ensure you obtain the coverage you want when choosing health insurance that covers bariatric surgery.

Chances are if you live in New York, some form of bariatric surgery will be covered on your insurance plan. When The Affordable Care Act was enacted, it required certain states to provide bariatric surgery insurance coverage in all the Healthcare Marketplace plans.

How To Get Insurance To Pay For Bariatric Surgery

Step 1. Find out if your current policy is sufficient

Since each insurance company has its own approval process for bariatric surgery, it is important to find out exactly what they require before you schedule your weight loss surgery. First, you need to determine what type of coverage is offered under your current plan and if that is going to work for you. If the policy covers the type of surgery you need, the next thing to do is ensure you have fulfilled or can fulfill all the prerequisites they require.

If your current plan does not offer coverage for what you need, it is time to shop around for a new plan that does. Often you must wait until an open enrollment period but while you wait, you can begin to work toward the prerequisites the new plan will require.

Step 2. Choose a board-certified bariatric surgeon

Choose a knowledgeable bariatric surgeon who will accept your insurance and attend a consultation. During the consultation, you can get all your questions answered regarding procedures and which one is right for you.

Also, you can find out who is responsible in the surgeon’s office for handling the insurance claims. Normally, unless your insurance carrier is not very well known, the insurance specialist at the surgeon’s office should have some knowledge of how best to prepare for gaining approval for bariatric surgery from that insurance company.

Most bariatric surgeons will help you navigate through all the insurance hoops because they have years of experience and know all the tricky nuances. It would be preferable to get everything right the first time because If you are denied, the appeal process can take several months.

Step 3. Make sure you meet the requirements

Before any health insurance policy will cover bariatric surgery, the patients must meet certain qualifications. The basic qualifications that all insurance companies require include:

  • The patient must be diagnosed by a doctor with a BMI of 40 or higher, or be at least 100 pounds overweight, or have a BMI of at least 35 and suffer from obesity-related comorbidity such as:
      • High blood pressure;
      • Type-two diabetes;
      • Severe sleep apnea;
      • Heart disease;
      • Or another medical condition that may be life-threatening and obesity-related;
  • Another prerequisite for bariatric surgery that insurance carriers have is that the patient must have tried other documented methods to lose weight and failed.

Documented methods of weight loss may include:

  • Membership(s) to the gym;
  • Membership and proof of participation with Jenny Craig or structured Weight Watchers programs;
  • Journals kept of attempted weight loss;
  • Food journals;
  • Medically supervised weight loss attempts;
  • Visits to dietician or nutritionist.

How Do You Know Which Insurance Covers Bariatric Surgery?

Finding out which insurance company would have the best coverage for your circumstances is often very challenging because one single insurance company often offers many different plans each that cover different elements. Plans also can change from one year to the next with a premium hike or changes in coverage.

Navigating your way through the maze of insurance companies to have bariatric surgery can be daunting and frustrating. The many qualifications and documentation that must be provided have to be done in the right time frame and in the correct format. Once again, working closely with the bariatric surgeon of your choice will be invaluable during this process.

If you are just beginning the process of insurance shopping, this guide from bariatric surgery sources online provides information on different insurance companies and bariatric surgery coverage. Of course, this should be used as a guideline and you will need to do your due diligence to determine specific details of your plan or desired plan.

Does Medicaid Cover Weight Loss Surgery?

Yes, Medicaid plans normally provide coverage for bariatric surgery however it may be challenging to find a bariatric surgeon who accepts the coverage. The rate of reimbursement that Medicaid provides is generally lower than other insurance companies and some surgeons do not accept the discounted rates.

Medicaid has a list of prerequisites within its qualification process but unlike many other policies, they include treatment for adolescents. These initial qualifications include:

  • The patient must have a BMI (body mass index) of 35 or more.
  • The patient must suffer from one or more obesity-related conditions such as type II Diabetes, high blood pressure, sleep apnea, etc.
  • The patient must have medical records documenting previous attempts at supervised weight loss efforts that have failed.

Provided the patient meets the prerequisites for surgery, both Medicaid and Medicare offer coverage for the following bariatric surgeries:

  • Laparoscopic gastric sleeve surgery;
  • Laparoscopic or open gastric bypass surgery;
  • Laparoscopic lap band surgery;
  • Laparoscopic or open biliopancreatic diversion with duodenal switch (BPD/DS).

The patient must be referred through the proper channels to gain approval. Most often, the primary physician refers the patient to a bariatric surgeon.

Does (BCBS) Blue Cross Blue Shield Offer Coverage For Bariatric Surgery?

Yes, some of the plans offered through Blue Cross Blue Shield cover weight loss surgery but each plan should be examined to determine the exact coverage provided. The pre-requisites of one Blue Cross Blue Shield plan include:

  • The patient must be at least 18 years old.
  • The patient must have a doctor-issued diagnosis of morbid obesity and possess a BMI of 40 or higher or at least 35 and be accompanied by at least one obesity-related condition such as high blood pressure, type 2 diabetes, etc.
  • The patient also must provide proof they have participated in a diet program that was supervised within the current 2 years before attempting the preapproval process for bariatric surgery.
      • Examples of these types of programs would include a 6-month (consecutive) structured program like Jenny Craig or Weight Watchers or two non-concurrent similar programs each at least 3 months long.
  • Patients are also required to submit to psychological testing to ensure they are not suffering from disorders that would inhibit their ability to implement and follow the necessary lifestyle changes to achieve weight loss. It also can reveal if the patient has a good understanding of what lifestyle changes would be needed, the risks, and possible long-term complications related to bariatric surgery and weight loss.

This BCBS Plan Provides Coverage for:

  • Gastric sleeve surgery;
  • Gastric bypass;
  • Gastric lap-band;
  • Duodenal switch;
  • Vertical banded gastroplasty.

It does not cover other procedures such as an intragastric balloon, mini bypass surgery, etc.

Why Does Insurance Cover Bariatric Surgery But Not Less Costly Non-Surgical Procedures?

The cost of a bariatric surgical procedure can average anywhere from approximately $16,000 to $28,000 according to the ASMBS (American Society for Metabolic and Bariatric Surgery) compared to the average cost of non-surgical weight loss procedures that average between $8,000-15,000.

Bariatric surgical procedures not only cost more but they are associated with higher risks of both short and long-term complications. It is difficult to comprehend why an insurance company would be willing to cover gastric sleeve surgery but not provide coverage for non-surgical endoscopic sleeve gastroplasty that provides the same results without surgery.

Suture Sculpt Endoscopic Sleeve Gastroplasty (ESG) more than proved its effectiveness in clinical trials where the target weight loss goal was 25% of the patient’s excess weight and the average weight loss actually achieved was 49%. These overwhelming weight loss numbers resulted in ESG becoming FDA approved for treating patients with obesity.

Suture Sculpt weight loss results after 1 year
Suture Sculpt weight loss results after 1 year

Despite the lower cost, evidence of results, lower risk profile, and faster recovery that ESG offers compared to laparoscopic bariatric surgery, insurance companies still do not offer coverage for this procedure.

Insurance companies have historically demonstrated reluctance in embracing new technologies and advancements in medicine and are generally slow to provide cover for new procedures The evidence from clinical trials coupled with the recent FDA approval will hopefully entice most carriers to offer health insurance coverage for non-surgical endoscopic sleeve gastroplasty. Bariatric surgeons are hopeful that this is the case in the not-too-distant future as it not only benefits the patient but the insurance company as well.

What Can I Do If I Don’t Have Insurance That Covers Bariatric Surgery?

If you discover that your current insurance plan does not cover bariatric surgery or does not provide the type of coverage you need, you may consider changing insurance companies or plans when open enrollment is available. In the meantime, you can familiarize yourself with the policies prerequisites and begin working to fulfill them along with the documentation they require.

If your insurance does not cover bariatric surgery and you are responsible for the costs of your weight loss surgery you may wish to:

  • Consider a less expensive non-surgical option such as the Orbera gastric balloon or Suture Sculpt endoscopic sleeve gastroplasty.
  • Ask your bariatric weight loss center about their financing plans.
  • Work with your primary practitioner to obtain many of the required medical tests through your normal health insurance. Many of the tests needed to ensure a patient is healthy enough to undergo surgery are routine tests that can be ordered for many different reasons. The primary doctor just needs to submit the tests under a CCP code that is not specifically used for weight loss. Although it may seem a bit suspect, it is ethical.

Getting your weight under control can potentially save or extend your life. Although it can be a significant financial challenge you should not let that stand in the way of your health. It will be one of the most important investments that you will ever make.

Contact Batash Endoscopic Medical Weight Loss Center today to learn more about non-surgical lower cost alternatives to bariatric surgery. We would love to share the weight loss potential offered by these less-invasive procedures, the lower risks, and shorter recovery with you to help you make an informed decision. Set up a consultation today.

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