Friday, April 12, 2024

Does Insurance Pay For Weight Loss Surgery

Does Insurance Cover Weight Loss Surgery 8 Key Questions Answered

Insurance and Other Payment Options for Bariatric Surgery

Looking to lose a few pounds? Youre not alonein fact, youre in the majority. In 2021, more than half of surveyed Americans were looking to lose weight.

For certain individuals, weight loss surgery may be a practical and effective option for losing weight quickly. However, as with all surgical procedures, costs can get high without insurance.

So, does health insurance cover weight loss surgery? And how much will you have to pay for it if you do or dont have health insurance?

This page answers key questions surrounding weight loss surgery and insurance coverage so you can feel confident knowing exactly how much youll be responsible for paying.

In the future, be sure to work with a transparent and digital-first insurance company that allows you to easily access information about your plan. When you can see the specifics of your plan at a glance, you can spend less time managing your plan and more time accessing the healthcare services you need.

How To Get Around Bariatric Exclusion

Obesity is easily one of the greatest threats to the health of America. Costs associated with obesity in this country are nearing an estimated $200 billion every year, including direct costs such as surgeries and medications, and treatments of certain diseases.

Indirect costs play a part in the overall health care price tag too. Unfortunately, some insurance companies view bariatric or weight loss surgery as something other than a medical necessity. This is often referred to as a bariatric exclusion in certain plans.

Plans may also charge more to cover weight-loss surgeries or procedures. At least half of the people in the United States get their health care insurance through their employer. Bariatric exclusion is one way to keep their health care costs lower for their employees.

What States Require Insurance Companies To Cover Weight Loss Surgery

As mentioned, about half of the states in the U.S. require ACA-compliant health plans to cover weight loss surgery for all patients who qualify for these procedures. Keep in mind that this does not apply to private health plans or group health plans. According to Dr. Garber, these 23 states include weight loss surgery as an Essential Health Benefit with every Marketplace health plan:

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Is Morbid Obesity Or Obesity Covered By Your Individual Policy

Contact your insurance provider to determine if obesity is covered. You can find your insurance providers phone number on the back of your insurance card.

Give your provider the ICD10 code E66.01 or code E66.0 .

If morbid obesity or obesity is a covered benefit, check that the procedure you are considering is also covered by giving your insurance provider the following codes:

Ask if Duke Regional Hospital, Duke Raleigh Hospital, Regional Anesthesia, Duke Department of Psychiatry, and the physicians of the Private Diagnostic Clinic at Duke University Hospital are accepted by your insurance.

You should also ask:

  • What percent of the total bill will I be responsible for?
  • Will I need to pay a deductible?
  • Are there specific criteria I need to meet to be considered for weight loss surgery?

Should I Pay In Cash Or Use Insurance

Is Weight Loss Surgery Covered by Insurance??

When considering getting a bariatric procedure done, insurance is the ideal way to go. However, whether you should pay out of pocket or through insurance will depend on the type of policy you have. Today, most major insurance carriers cover laparoscopic gastric bypass, gastric sleeves, and lap band surgeries. However, that does not mean your health plan also provides coverage for such procedures.

While some plans entirely exclude bariatric surgery, others may require you to pay more to include coverage for weight loss procedures, Read your individual health policy carefully or ask your agent to know whats covered and whats not.

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Aetna Bariatric Surgery Requirements

If your employer has provided you an Aetna health insurance policy, you will need to meet the following Aetna bariatric surgery requirements in order to qualify:

  • You must have a BMI of 40 or more.
  • You must have a BMI of 35 and at least one of these diseases: type 2 diabetes, coronary heart disease, severe hypertension, or severe sleep apnea.
  • You must show proof that you have attempted weight loss in the past and failed.
  • You must show proof that youve participated in at least one weight loss program under medical supervision.

Insurance Coverage For Weight Loss Surgery

Insurance coverage for obesity surgery varies according to the insurance carrier. Those that cover bariatric, or weight loss, surgery often limit their coverage to certain types of surgery.

Insurance companies that cover bariatric surgery have varying requirements. Some may require medical records documenting that you have medical problems caused by your weight or records of your participation in medically supervised weight loss programs. In fact, many insurers require at least six months participation in a supervised weight loss program within two years of your proposed surgery date.

Our office participates with many insurance plans. But whether we participate or not, our surgical scheduler can work with you and your insurance company to obtain authorization for your surgery. Each insurance plan is unique, and getting authorization for surgery is often a long, labor-intensive process.

Prior to visiting our office, please:

  • Write down the name of the person you speak with, including first name, last name, and direct phone number.

Your insurance carrier may request the name of the surgery and the CPT/ICD-9 codes. Insurance companies use the following codes to identify the type of procedure or surgery:

  • Lap Gastric Banding: 43770
  • Lap Gastric Sleeve: 43775
  • Diagnosis Code for Morbid Obesity: E66.01

When you have a surgery date, it may take another two weeks to two months to obtain approval from your insurance carrier.

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Q Why Are Weight Loss Services Not Covered Under My Insurance

A. Weight gain is sometimes the result of a specific medical condition or a side effect to treatment of a medical condition. Weight loss may even be recommended as treatment for a chronic medical condition. Despite these facts, few medical insurance policies will cover services for the sole purpose of weight loss. Your insurance carrier may tell you that they pay for services, labs, or tests included in our weight loss programs. This is true however these services must be associated with a limited set of diagnosis codes. Currently insurance carriers are reluctant to pay for any service associated with the diagnosis of overweight, weight gain or obesity.

You are responsible for verifying that your insurance company pays in a timely manner. Fulfilling this responsibility may require you to contact your insurance company. Your coverage is between you and your insurance company. We will help you present your claim, but you must take ultimate responsibility for your account.

What Are The Criteria To Get Weight Loss Surgery Covered By Insurance

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

Does my insurance cover weight loss surgery? As with many healthcare services, the answer is that it depends.

To start, every insurance company is different, meaning there are no rigid standards that every company in the country needs to adhere to. That being said, there are some general guidelines that the majority of insurance companies choose to follow, and in some cases, due to state guidelines, must follow.

In general, to qualify for insurance coverage for weight loss surgery, the following criteria must be met:

  • You have a body mass index of 40 or higher OR you have a BMI of 35 to 40, and you also have a serious or life-threatening health complication related to obesity, such as heart disease or high blood pressure
  • You have already tried to lose weight through a medically-approved weight loss program and not had success

Curious what your BMI is? The CDC offers a free BMI calculator for adults. Just enter your height and weight and tap Calculate.

For more information on BMI in general, visit the CDC.

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Are Weight Loss Programs Covered By Insurance

The National Conference of State Legislatures says 16 states require plans to cover some weight loss programs, including at least some coverage and reimbursement for:

  • Dietary or nutritional screening
  • Counseling and/or therapy for obesity, sometimes including weight loss programs

Another seven states require coverage for nutritional counseling or therapy, but only when the diagnosis or treatment is related to diabetes.

The weight loss programs that are covered and the amount of coverage varies. Weight Watchers, for example, may be covered by some insurance, or the insurance company may offer a discount through a wellness benefit.

How To Get Insurance To Pay For Bariatric Surgery

For an increasing number of patients, weight-loss surgery can offer a way to improve their health and quality of life. Forecasts predict that the bariatric surgery market will grow at a compound annual growth rate of 9.56% from 2019 to 2028. And with the average cost running between $15,000 to $36,000, insurance coverage is an important consideration for the majority of patients. You can simplify the insurance process for your surgical patients by learning how to get insurance to pay for bariatric surgery.

Read on to know which states require insurance plans to cover bariatric surgery and the typical insurance criteria for bariatric surgery coverage.

Key Takeaways

  • Most insurance covers bariatric surgery. Coverage of bariatric surgery is a requirement for all individual, family, and small group insurance policies in 23 states.
  • The majority of insurers require a BMI of at least 40 for patients to qualify for bariatric surgery coverage.
  • Other typical criteria to demonstrate the medical necessity of bariatric surgery include past attempts at weight loss, passing a psychological evaluation, the cessation of smoking, and no evidence of substance abuse.

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What Is A Letter Of Pre

A letter of pre-determination or pre-certification from your insurance company means their medical review department has decided, based on the information provided, that your surgery is medically necessary. But this does not mean they will cover your surgery. That depends on your individual insurance policy.

We will submit the necessary documentation to your insurance company. Please do not ask any other physician to submit anything directly to your insurance company. They can provide necessary documentation to us, and we will submit everything as the insurance company requires.

How To Get Approved For Weight Loss Surgery In Mexico

7 Types of Weight Loss Surgery

Since weight loss surgery costs around $15,000 $30,000+ in the US, more and more patients are heading over to Mexico to receive the procedure. Statistics show that almost 1.4 million Americans crossed the border in 2018 to undergo medical treatment including some form of bariatric surgery.

If your insurance carrier is refusing to cover your bariatric procedure and youre wondering how to get weight loss surgery approved in Mexico, here are some simple guidelines for you:

You have to meet the following criteria to be eligible for weight loss surgery in Mexico:

  • You must have a body mass index of 30-35
  • You must have BMI for gastric sleeve of 35-40+
  • You must be suffering from obesity-related illnesses like diabetes, breathing issues, heart problems, hypertension, etc.

Bariatric surgery in Mexico costs around $3,599 $5,500 for inpatient treatment. This means everything from ground transportation and hotel stay to cost of medications is included in this price tag. However, if you cant afford to pay for the surgery all at once, our Jet Medical Tourism® team can provide you with super affordable payment plans as well.

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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.

What Can I Do If Weight Loss Surgery Isnt 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

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 plans 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.

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What Can I Expect With An Adolescent Laparoscopic Sleeve Gastrectomy Weight Loss Surgery

Weight loss surgery changes how the body handles food and beverages. In order to allow the stomach to heal, weight loss surgery patients will be placed on a special meal plan. A very specific diet must be followed for 6 weeks. This diet restricts the types of foods and how much to eat and drink. After the first 6 weeks, there will be other very specific dietary recommendations.

Gastric Sleeve Insurance Coverage: Criteria Varies By Insurer

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Insurance carriers cover the cost of gastric sleeve surgery if you meet certain pre-specified criteria, which vary by company. Most insurance companies/employers that offer gastric sleeve surgery insurance coverage require a body mass index equal to or greater than 40for gastric sleeve surgery, or a BMI of 35 if there are significant medical problems associated with your weight, like Type 2 diabetes, hypertension, sleep apnea and heart disease. A BMI of 40 or above is the equivalent of being about 100 pounds overweight for men and 80 pounds overweight for women.

Disparities in gastric sleeve insurance coverage are common. United Healthcare will cover the cost of gastric sleeve surgery for individuals with a BMI of 40 or higher, or a BMI 35 to 39.9 and one obesity-related illness. Other insurers have significantly higher BMI requirements because they have not updated their requirements to include the gastric sleeve as a standalone, primary bariatric surgery procedure. For example, Blue Cross-Blue Shield Arkansas requires a BMI of 60 or higher for gastric sleeve surgery coverage. If a person has severe heart and lung problems associated with obesity, however, they may lower the BMI requirement and cover the costs of gastric sleeve surgery.

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Cosmetic Surgery After Bariatric Surgery

Many patients decide to have cosmetic surgery after bariatric surgery to remove excess skin. In general, insurance companies do not cover cosmetic surgeries, unless they are needed to resolve a medical issue, such as problems with your skin folds. It is important to explore these questions with your physician and your health plan.

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 companys 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 surgeons 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

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
  • Previous medically supervised weight loss diets
  • Nutritionist Visits.

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Paying For Your Bariatric Surgery

The cost of bariatric surgery depends on your insurance coverage and the procedure performed. Generally speaking, a patient paying cash for a procedure will pay between $12,500 and $31,000.

Most insurance companies and Medicare cover bariatric surgery however, every plan differs. We will help you verify that your benefits include bariatric surgery, and we will help you determine what, if any, co-payments and deductibles you will be responsible for.

While Medicaid is accepted at both locations, it does not cover all costs. As with all medical procedures, it is important to understand what will and will not be covered by your individual plan. If you do not see your insurance here, please contact our office, as contractual arrangements are subject to change.

  • ASR Physicians Care
  • Blue Care Network Medicare Advantage
  • Blue Cross Blue Shield Traditional
  • Blue Preferred PPO/Community Blue PPO
  • Priority Health Medicare
  • United Healthcare
  • Traditional Medicare

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