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Will Health Insurance Pay For Weight Loss Surgery

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Dr. Aram Jawed: Does medical insurance cover Weight Loss Surgery?

Payment may be denied because there may be a specific exclusion in a patients policy for obesity surgery or “treatment of obesity.” You can appeal such exclusions by submitting a personal written request to the benefits manager within the insureds place of employment and ask for an exception to policy. Insurance payment could also be denied for lack of medical necessity.” A therapy is deemed to be medically necessary when its needed to treat a serious or life-threatening condition. In the case of morbid obesity, alternative treatments such as dieting, exercise, behavior modification and some medications are considered viable and available. Medical necessity denials usually hinge on the insurance company’s request for some form of documentation, such as physician-supervised dieting or a psychiatric evaluation proving that youve tried unsuccessfully to lose weight by other methods.

How Long Does It Take Medicaid To Approve Weight

Medicaid also allows weight-loss surgeries if you meet criteria, but recent studies show approval make take longer.

Insurers usually take a month to approve weight-loss surgeries. However, wait times for Medicaid approval can take five months or more. During that time, Medicaid will review your records and input from your doctor before making the decision.

Is Bariatric Surgery Covered By Insurance

Most commercial insurance plans approve all four typical weight loss surgical procedures gastric bypass, vertical sleeve gastrectomy, gastric banding with LAP-BAND® or REALIZE® bands, or duodenal switch procedures for the appropriate patients.

To receive approval, a patient usually needs to have a BMI above 40, or a BMI between 35 and 39 if the patient also has certain medical conditions such as diabetes, sleep apnea, or high blood pressure. Some insurance companies have a mandatory three-month weight management protocol that you must complete before surgery. Some have a protocol as long as six months.

For all plans, dietary and psychological evaluations are mandatory. This is a practical step that helps ensure your readiness for the procedure.

Your medical team can work with you to help you meet the particular requirements of your health plan in order to qualify for insurance coverage.

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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:

  • Diabetes
  • 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
  • 8.48% for Medicaid
  • 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 can’t 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 don’t 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.

How We Can Help

Medicare weight loss surgery: Coverage, risks, and costs

Our goal is to help you understand your specific benefit coverage and to educate you on your covered benefits, out-of-pocket expenses and our self-pay options. Our program accepts a variety of health insurance plans, but coverage varies widely. We work with you to determine what your specific policy covers. While we do not give financial advice, we can help you understand your options.

If insurance is not an option, you may choose to pay for surgery on your own. Our patients fund the cost of the procedure through a variety of ways, including:

  • Cash payments
  • Gifts from family and friends
  • Loans from financial institutions

Regardless of which option is used to pay for weight loss surgery, our patients overwhelmingly tell us the decision to have weight loss surgery was well worth the investment.

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Q: Will My Health Plan Cover Weight

A: This is less likely than your health insurance covering weight-loss counseling or even surgery. Still, review your policy. Focus on the section that discusses exclusions–it should tell you if your plan covers the drugs you’re looking to take or not. If this doesn’t help, contact a company representative.

It isn’t unusual, though, for health insurance to refuse to cover these kinds of medications.

Q Will My Health Plan Cover Bariatric Surgery

A. Depending upon your type of insurance plan there may be exclusions for weight loss treatments, including surgery. Your insurer may require you to meet certain conditions before having the procedure or to demonstrate that other methods for weight loss have failed. Other plans will have certain requirements before agreeing to pay for the surgery, such as a medically supervised diet history and the need for psychological evaluation. Not all plans have the same requirements. Obtain a printed copy of your insurance company’s requirements and document all contacts you have with the insurance company.

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Paying For Weight Loss Surgery

While the cost of bariatric surgery and related lifestyle changes can be considerable, the good news is that most health insurance plans provide coverage for weight loss surgery and related services to people who meet certain requirements. However, what insurance will pay for and how to qualify can differ greatly, even among plans offered by the same insurance company.

We understand this can be a confusing part of your weight loss journey. Thats why we do everything we can to help you understand your insurance benefits and what expenses you can expect that go beyond your insurance coverage.

Duke Regional Hospital is accredited by the American Society for Metabolic and Bariatric Surgery for its high standards of care in weight loss surgery.

How To Meet Insurance Criteria

Will Insurance Cover My Weight Loss Surgery?

Once your benefits have been confirmed, youll meet with a surgeon to consult. Your height, weight and BMI will be documented as well as comorbid conditions and tried and failed attempts at conservative, non-surgical weight management. If your plan requires a medically supervised weight loss program, youll start seeing a dietitian, typically on a monthly basis for the specified duration.

The most common insurance criteria is a psychological clearance, so you should plan to schedule an appointment with a mental health professional who will evaluate you to determine candidacy for bariatric surgery. It is important to rule out psychological disorders, disordered eating of any type, inability to provide informed consent or inability to comply with pre- and post-surgical recommendations.

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Q: Does Medicaid Cover Weight

A: Many Medicaid plans do cover counseling and surgical procedures that promote weight loss. Whether or not yours covers these treatments, though, depends on where you live. To find out one way or the other, review your policy. If that doesn’t clarify matters, contact your state’s Medicaid agency.

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Which States Require Insurance To Cover Bariatric Surgery

Weight loss surgeries, generally referred to under the umbrella term bariatric surgeries, make physical changes to your digestive tract to aid in weight loss.

Although not the only one, gastric bypass is a very common type of bariatric surgery where the surgeon creates a small pouch and connects it to the small intestines.

Gastric bypass surgery patients are less likely to overeat because the pouch is smaller than the stomach, meaning it gets fulland you feel fullmore quickly.

23 states require healthcare plans to cover bariatric surgery: Arizona, California, Colorado, Delaware, Hawaii, Illinois, Iowa, Maine, Maryland, Massachusetts, Michigan, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia, and Wyoming.

Georgia, Indiana, and Virginia also require healthcare plans to cover bariatric surgery, but only under certain types of plans.

If youre looking to lose weight but youre not sure if you want to make the leap to weight loss surgery quite yet, your state may require insurance companies to offer a less invasive alternative. 16 states require healthcare plans to include some sort of reimbursement for weight loss counseling, and an additional seven states cover nutritional counseling, but only if a diabetes-related diagnosis has been made.

Visit the National Conference of State Legislatures for a full list of which states cover which weight loss-related treatment options.

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Patient Centered Medical Home Award

Medical Weight Loss Services

Our medical weight-loss program is an ideal option for people who want to lose weight but are not interested in bariatric surgery. Unlike commercial weight-loss products and fad diets that promise a quick fix, our weight management services are supervised by a team of specialists, including obesity medicine doctors, registered dietitians, exercise specialists, and psychologists.We help you address all the behavioral and lifestyle choices that contribute to weight gain so you achieve results that last. And because obesity affects people of all ages, our medical weight-loss program is open to anyone who meets eligibility criteria. If you are under the age of 18, take a look at our pediatric weight management services.

We help you create a customized diet and fitness plan and provide any prescription medicines or counseling you may need. You also have access to unique on-site amenities such as our clothing closet, fitness center, and demonstration kitchen.

What If My Insurance Doesnt Cover Weight Loss Surgery

Does Health Insurance Cover Weight Loss Surgery?

If your insurance doesnt cover weight loss surgery, you are not alone. Unfortunately, according to the American Society for Metabolic and Bariatric Surgery, less than 1 percent of those who meet the criteria for surgery actually have surgery5. A big reason for this is lack of insurance coverage.

If you find you do not have insurance coverage, there are self-pay surgery options available . The self-pay cost of weight loss surgery procedures varies by the type of procedure and geographical area in which it is offered . Generally speaking, the average cost for a gastric bypass ranges from $18,000 to $25,000, while the adjustable gastric banding surgery costs anywhere from $17,000 to $30,000. The sleeve gastrectomy procedure is newer and a price range is not as readily available. A ball Park Range is anywhere from $14,000 to $22,000. The price range is also influenced by the supportive program aspects that may or may not be included, the number of follow-up visits, and for the laparoscopic adjustable banding, whether or not any adjustments are included.

  • Gastric Sleeve $13,995.00
  • Laparoscopic Adjustable Gastric Band $16,995.00
  • Gastric Bypass $18,995

However, in addition, an exclusive comprehensive 12 month program is included with these fees. It is called Weight Management University for Weight Loss Surgery and includes the following:

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Gastric Sleeve Insurance Coverage: Other Options

If you choose to pay cash for gastric sleeve surgery, complications may not be covered. Some bariatric surgery centers may offer âreinsuranceâ plans that will cover the cost of complications during the first year after surgery if you pay cash for your gastric sleeve surgery.

You have options, and discovering them is just a phone call away. Call our Gastric Sleeve Insurance Experts Hotline at or fill out our FREE No Obligation Gastric Sleeve Insurance Verification Form.

United Healthcare Bariatric Surgery Requirements 2020

If you want to know how to get weight loss surgery approved by United Healthcare, you have to meet the following criteria:

  • You must be 18 years of age or older.
  • You must have a BMI of 40 or more.
  • You must have a BMI of more than 35 and at least one obesity-related issue, like severe sleep apnea, stroke, hypertension, or type-2 diabetes.
  • You must show proof that you have followed weight loss diets in the past and failed.

CHECK THIS OUT: How quickly can I get bariatric surgery?

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What To Do If Your Insurance Provider Denies Your Request

If your desired procedures arent covered youve still got a few options at your disposal. The first option is to finance the process yourself. You can take out medical loans, and your doctor may be able to assist you in finding financial institutions that he or she has previously worked with. Additionally, you are allowed to make changes to your insurance at least once a year .

If your current coverage doesnt cover your bariatric treatment, spend time looking into policies that do cover your intended procedures, and work to make a policy change when the time comes. If your insurance is offered by your employer and doesnt seem to offer the benefits that youre looking for, consider finding your own insurer or a new employer with better benefits.

Talk to your doctor and maintain a healthy relationship with the health care professionals that are assisting you. This will make it easier for you to obtain physician letters, consultations, and advice from individuals who work with insurance companies daily. They have intimate knowledge of what can and cannot be approved.

Does Insurance Cover Bariatric Surgery

Will my medical insurance cover weight loss surgery?

Bariatric surgery can be an expensive procedure, often costing tens of thousands of dollars. In the U.S., many insurance plans cover bariatric surgery when a patient meets certain criteria.

According to a recent survey of coverage criteria for bariatric surgery, 95% of companies have a clearly defined pre-authorization policy. They all covered Roux-en-Y bypass surgery, and most also covered laparoscopic adjustable gastric banding or sleeve gastrectomy.

The majority of insurers required BMIs of 40 and above, or 35 and above with a co-morbidity present, and a supervised medical weight management program prior to the approval of bariatric surgery.

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Frequently Asked Questions About Weight Loss Surgery

  • Does Medicare cover weight loss surgery?

    Yes, Medicare can cover weight loss surgery, but only if it’s deemed medically necessary and you meet specific requirements . You also won’t be approved until you meet with a physician for an in-depth, face-to-face consultation.

  • How much is weight loss surgery without insurance?

    In Australia, weight loss surgery can cost as much as $20,000 without insurance. In some cases, depending on the type of surgery you receive, it can cost even more.

  • Are there waiting periods for weight loss surgery?

    Yes. You will have to hold health insurance that covers weight loss surgery for 12 months before you are covered. It’s included with all gold-level hospital policies.

States Where Insurance Is Required To Cover Bariatric Surgery

Under the Affordable Care Acts Essential Health Benefits Benchmark Plans, 23 states require that all individual, family, and small group insurance plans cover bariatric surgery. Those states are:

  • Arizona
  • West Virginia
  • Wyoming

Also under the ACA, in the following three states, bariatric surgery coverage must be offered in at least some policies:

  • Georgia, where a 1999 state law also mandates coverage for morbid obesity
  • Indiana, where a 2000 state law also mandates coverage for morbid obesity
  • Virginia, where a 2000 state law also mandates that coverage for morbid obesity must be offered in at least one plan by each state-regulated health insurer

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Who Needs To Undergo Weight Loss Surgery

Anyone with a BMI of over 35 is recommended to undergo bariatric weight loss surgery.

This is an excellent and effective way to lose additional weight and minimize the risk of developing health complications, such as high blood pressure, type 2 diabetes, depression, breathing problems, and even cancer.

What Insurance Companies Cover Weight Loss Surgery

In simple words, if you weigh over around 200 lbs. then you should undergo weight loss surgery if the doctor advises you to.

Apart from this, if you have a family history of obesity, or tend to gain weight fast, then bariatric weight loss surgery is highly advised for you.

Does Insurance Cover Obesity Weight Loss Drugs

Weight Loss Surgery Health Insurance Coverage

Some health insurance companies cover obesity drugs, but other insurers balk at covering such medicines.

Once you go on an obesity medication, you generally have to stay on it for life, Stegemann says. And so its a cost concern for them.

If your doctor prescribes medications for overweight or obesity, contact your health insurance company to find out if it will cover them. You might find the information on your health insurers website. Or, you can learn more by calling a customer service representative and asking questions such as:

  • Which medications are covered and for how long?
  • Will I owe a copay?
  • Am I restricted to getting my medicines from specific pharmacies?

As a general rule, Medicare doesnt cover weight loss medications.

Original Medicare benefits dont offer coverage for any prescription medications for Medicare recipients except those administered during an inpatient hospital stay or in an outpatient setting. To date, no weight loss medication qualifies under these terms. Medicare Part D prescription drug plans also typically dont cover weight loss medications.

Does Medicaid cover weight loss pills? No, as with Medicare, weight loss medications arent covered.

Stegemann laments that so many patients cant get their medication costs covered.

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