Thursday, April 11, 2024

What Insurance Covers Bariatric Surgery In Georgia

Criteria For Weight Loss Surgery Cost Coverage Through Medicaid

Does your Insurance cover Bariatric Surgery?

In order for Medicaid to completely cover the cost of your surgery as well as the associated visits with your surgeon, you are going to need to meet all of the following criteria.

  • You will need to be over the age of 13 if youre a female or over the age of 15 if youre a male.
  • Your Body Mass Index must exceed 35 and you must have at least one comorbidity, such as high blood pressure, sleep apnea, high cholesterol, or diabetes.
  • If you are below the age of 21, you need to have a Body Mass Index exceeding 40 with at least one of the aforementioned comorbidities.
  • You must have a printed letter from your primary care physician recommending the medical necessity of weight loss surgery.
  • You need to pass a mental health exam showing that you are capable of adopting the necessary lifestyle changes for weight loss.
  • You must be able to provide documentation showing that you have tried to manage your weight and comorbidities using standard treatment, but that those attempts were unsuccessful.
  • You must complete a medically supervised program for weight loss spanning 6 months, and you need to show documentation that this weight loss program was attempted within the past 12 months before surgery.

Some people will not qualify for weight loss surgery through Medicaid. If you have any of the following conditions or issues, you will not qualify.

  • Long-term use of steroids
  • Chronic pancreatitis, inflammatory bowel disease, or pregnancy
  • Non-compliance with medical treatments

Are Gastric Bypasses Worth It

For some patients, having a bariatric procedure, like gastric bypass, is worth it. For a committed patient, weight loss surgery is an effective tool for losing weight. It has also shown to be effective at reducing the impact of many obesity-related conditions such as type 2 diabetes, sleep apnoea, and heart disease.

Rationale For Completing Program Prior To Surgery

The patients ability to lose weight prior to surgery makes surgical intervention easier and also provides an indication of the likelihood of compliance with the severe dietary restriction imposed on patients following surgery.

Given the importance of patient compliance on diet and self-care in improving patient outcomes after surgery, the patients refusal to even attempt to comply with a nutrition and exercise regimen prior to surgery portends poor compliance with nutritional and self-care requirements after surgery. Therefore, the appropriateness of obesity surgery in non-compliant patients should be questioned.

The patient must be committed to the appropriate work-up for the procedure and for continuing long-term post-operative medical management, and must understand and be adequately prepared for the potential complications of the procedure.

There is rarely a good reason why obese patients can not delay surgery in order to undergo behavioral modification to improve their dietary and exercise habits in order to reduce surgical risks and improve surgical outcomes. The patient may be able to lose significant weight prior to surgery in order to improve the outcome of surgery.

An individuals understanding of the procedure and ability to comply with life-long follow-up and life-style changes are necessary for the success of the procedure.

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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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Weight Loss Surgery For Medicare Plans

What Health Insurance Covers Gastric Bypass Surgery

All Medicare plans are required to cover the following weight loss surgery procedures:

  • Duodenal Switch
  • Vertical Banded Gastroplasty

Please see below for the procedures Anthem Blue Cross Blue Shield covers, might cover under certain circumstances, and those that are not covered under any circumstances:

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Blue Cross Blue Shield Bariatric Surgery Policy

Does Blue Cross Blue Shield cover weight loss surgery? In general, the answer is yes, it does. However, the insurers in every state may have different rules for different groups. Moreover, each patients Blue Cross Blue Shield bariatric surgery policy may have slightly different terms and conditions, exclusions, and coverage limits.

  • When buying a Blue Cross Blue Shield weight loss surgery policy, find out which procedures are covered and what are the exclusions.
  • If you have insurance from your employer or through your spouses employer, check if they have opted out of BCBS bariatric coverage.
  • In a situation where Blue Cross Blue Shield bariatric surgery policy coverage is denied, check for clerical errors and ask for a reason.
  • In case of pre-authorization denial of Blue Cross Blue Shield weight loss surgery policy, consider filing an appeal with the insurer.
  • If your Blue Cross Blue Shield policy does not cover bariatric surgery, consider the lowest self-pay options and medical care financing.

Learning The Basics Of Bariatric Surgery

Bariatric surgery, commonly known as weight loss surgery, alters persons digestive process within the gastrointestinal tract to assist the person in losing weight. There are 2 types of bariatric surgical techniques: restrictive and malabsorptive. These 2 techniques can also be combined to form a third technique. Most procedures are performed using a laparoscopic or open approach.

  • Restrictive procedures: Reduce the stomach size thus decreasing the amount of food the stomach can hold
  • Malabsorptive procedures: Limit the amount of nutrients and calories that the body can absorb

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Anthem Weight Loss Surgery How To Avoid A Denial

Your Anthem Blue Cross Blue Shield weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.

First, try our insurance tool to quickly check your insurance coverage:

Read and click below for additional weight loss surgery insurance details.

  • 35+ Body Mass Index
  • Documentation of failed diet attempts
  • Psychological evaluation

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How Well It Works

Bill Proposes Health Insurance Coverage For Bariatric Surgery

Depending on the type of surgery, most people lose at least a third of their extra weight after surgery. Some people lose almost all of their extra weight. Weight loss varies with the type of surgery. It also depends on how closely people follow their doctor’s advice for lifestyle changes, checkups, and counseling.

Research shows that people who have gastric bypass surgery lose more total weight than those who have gastric sleeve or gastric banding surgery. But those who have gastric bypass surgery have more complications right after surgery. footnote 1

Here are some risks common to all surgeries for weight loss:

  • You could get an infection in the incision.
  • You could get a blood clot in your legs .
  • You may not get enough of certain vitamins and minerals. This can lead to problems such as anemia
  • kidney stones .
  • You may gain the weight back a few years after surgery if you don’t follow your eating and lifestyle plan.

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Bariatric Insurance Pricing And Financing

Well work with you to put weight-loss surgery at OHSU within reach.

  • If you have health care insurance, we can help you seek authorization for bariatric treatment.
  • If you dont have insurance, call our scheduling coordinator at to learn about other options.
  • We offer some of the lowest pricing in Oregon.
  • We can direct you to a financing option.

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How Much Does Gastric Sleeve Surgery Cost

According to one research, it takes an average of three years from the time you contemplate gastric surgery to the time you actually get it. You may spend many hours studying, reading, and speaking with post-operative patients regarding their procedures.

But, how much is gastric sleeve surgery? A Gastric sleeve surgery costs an average of $23,000, while a gastric bypass surgery costs $14,500, and sleeve gastrectomy surgery costs $14,900. So, before you get too excited, find out if your insurance will cover weight reduction surgery or not.

Patients belonging to the middle to upper classes are the majority of people who undergo this surgery. In addition, most people considering weight reduction surgery may not afford to pay the $20,000 gastric sleeve cost to reduce weight.

However, insurance companies are also beginning to pay weight reduction surgery amounts in more significant numbers than ever before. So, if you are determined to get this even after knowing how much is gastric sleeve surgery, talk to your insurance provider.

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If Your Policy Does Not Cover It: Seek Partial Coverage

You may be able to get part of the costs paid for by insurance even if weight loss surgery isnt covered. Its all about how your doctor and hospital submit your claims to your insurance company.

For example, there are many non-bariatric surgery reasons for your doctor to recommend:

  • Cardiology exam
  • Psychological exam

These are ordered for many reasons other than bariatric surgery and may be covered as a result. If your doctor submits one of these claims using a weight loss surgery CPT code , your insurance is unlikely to cover it. But if your doctor uses a general CPT code, it probably will be covered.

While this may sound sneaky, it is an ethical practice. After all, these tests will be beneficial regardless of whether you move forward with surgery.

Find A Weight Loss Surgeon

does medicaid cover weight loss surgery in north carolina

SECTION SUMMARY:

  • You can ask a local bariatric practice for a free insurance check or cost quote
  • You can attend a free in-person seminar or an online webinar offered by a local weight loss surgeon
  • You should schedule a phone or in-person consultation , if you are interested in learning more about weight loss surgery

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Should I Pay In Cash Or Use 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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Past Attempted Weight Loss

In most cases, insurance companies require that your patient has made sufficient efforts to lose weight before theyll approve coverage for bariatric surgery. This can include completing a medically supervised weight-loss plan developed by the insurance provider or making other efforts to lose weight as recommended by a doctor. Generally, insurers require the program or efforts to last from three to seven consecutive months.

If your patient has been unsuccessful in their weight-loss efforts after this period, they may then be considered a candidate for bariatric surgery. You will likely need to provide documentation of the attempts to lose weight, including dietary and exercise regimens, to gain insurance approval.

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Qualifying For Bariatric Surgery:

A person must have a body mass index of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to:

  • Diabetes mellitus, Type II
  • Life threatening cardio-pulmonary problems,
  • Documentation of all of the following:

  • Participation in a weight loss program. The individual must have actively participated in the program for at least 3-6 months and
  • Pre-operative medical and mental health evaluations and clearances and
  • Pre-operative nutritional counseling with a Registered Dietitian and
  • Pre-operative education which addresses the risks, benefits, realistic expectations and the need for long-term follow-up and adherence to behavioral modifications
  • **Please Note: All clinical guidelines and qualifying factors vary based on insurance company and the policies in place. If you have specific questions regarding your health insurance policy, please contact our office at , option 2.

    The University of California, Los Angeles is designated as:

  • United Health Care Optum Center of Excellence Network
  • Blue Cross Blue Shield Bariatric Resource Service
  • Aetna Institute of Quality
  • MBSAQIP Accredited Center
  • Medicaids Requirement For Weight Loss Surgery

    Does Medicare cover bariatric surgery?

    Medicaids requirements for weight loss surgery coverage are a little different as compared to other insurance plans. Typically, this is because Medicaid is unique in who they cover and how they cover their patients.

    You need to meet a number of specific requirements in order to qualify for weight loss surgery through Medicaid, and you also need to be free from any medical issues that would prevent you from having surgery. If you pass these two tests, then Medicaid will generally pay for your weight loss surgery.

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    Does Anthem Blue Cross Cover Lap Band Surgery

    Yes, Anthem Blue Cross covers lap band surgery provided you fulfill the eligibility criteria for this weight loss procedure. Make sure to carefully go through your insurance policy document to know which expenses related to your lap band surgery are covered. Its always a wise idea to call your insurer and ask them to verify your actual Anthem Blue Cross lap band surgery coverage for you.

    • Lap band is a less frequent weight loss procedure, and Anthem Blue Cross lap band coverage may require a surgeons recommendation.
    • The pre-approval criteria and actual lap band coverage may vary for each patient and for each Anthem Blue Cross insurance plan.
    • Apart from meeting the BMI eligibility requirements, you may have to submit a letter detailing your weight loss efforts in the last 5 years.
    • Your co-morbidities will be evaluated if your BMI is less than 40 before you get Anthem Blue Cross lap band surgery authorization.
    • Depending on your lap band coverage, you may have to undergo up to one year of medically supervised non-surgical weight loss program.
    • Lap band fills cost is included in your Anthem Blue Cross lap band coverage, if your prior lap band surgery met the required conditions.

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    So How Does Bariatric Surgery Insurance Work

    Few years back, bariatric surgery was a standard exclusion across the industry. However, with the changing needs of the world and the technical advancements, bariatric surgery is considered by many insurance companies now. If you are hospitalized for a Bariatric Surgery which is medically necessary, on the advice of a Medical Practitioner, we cover the related medical expenses. However, it is to be kept in mind that Bariatric Surgery Insurance benefit can be availed only when it is medically necessary and not for cosmetic purposes.

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    Risks Of Each Type Of Surgery

    Talk to your doctor to understand all of your risks. Here are some of the most common or serious risks for each type of weight-loss surgery:

    Adjustable gastric banding.

    After this surgery, you are more likely to need another surgery to fix problems than you would after gastric bypass. For example, some people need a second surgery because they aren’t happy with having the band. Or the band can slip. Or it can work its way from the outside of the stomach to the inside. This is called an erosion.

    Gastric bypass and gastric sleeve surgeries.

    These can cause a leak from the stomach into the belly area. The leak can cause an infection called peritonitis.

    Gastric bypass.

    With this surgery, the connection between the stomach and the small intestine can get narrow. This can cause nausea and vomiting after you eat.

    The Use Of Health Insurance For Bariatric Surgery

    Sample of Healthcare Projects on Behance

    With the high costs associated with Bariatric Surgery, it may lead to the question of using health insurance to cover the cost Either partially or completely.

    While this will change based on each individual health insurance company and coverage, there are usually base requirements to qualify for insured coverage of the procedures.

    Most insurance companies may require:

    • Proof that the surgery is medically necessary
    • Previous participation in physician-supervised diet & weight loss programs
    • A psychological & nutritional evaluation

    If you meet the above requirements, the surgeon can provide your insurance company with a pre-authorization document outlining the necessity of the surgery. Once done, its up to the insurance company to review the case and decide the next steps, whether that be to cover the cost of the surgery, or provide other solutions.

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    Gastric Sleeve Insurance Coverage: What Is Covered

    Almost all PPO Insurance companies recognize the necessity of the Gastric Sleeve operation for patients who have been unable to find success using other non-surgical weight loss methods. They understand that as you lose more weight, the less likely it is that you will suffer from other obesity-related conditions, such as type 2 diabetes, hypertension and obstructive sleep apnea.

    Gastric sleeve insurance coverage may also even include the post-operation elements that are necessary to be successful with your procedure such as support groups, exercise and nutrition counseling.

    Whether or not your coverage is denied, our trained staff of insurance professionals are experts at helping you get your gastric sleeve surgery approved. Just call our Gastric Sleeve Insurance Hotline at or fill out our FREE Gastric Sleeve Insurance Verification Form!

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