How to get your health insurer to pay for your weight-loss or bariatric surgery

According to the Centers for Disease Control and Prevention, adult obesity rates doubled in the past 30 years. Nearly 40% of adults are considered obese. At least 20% of adults in every state are obese.

Unfortunately, even if your body mass index (BMI) classifies you as obese, your health insurance company may not approve bariatric surgery.

What is weight-loss surgery?

Many have turned to bariatric surgery coupled with a change in diet and exercise as a way to lose weight. The American Society for Metabolic & Bariatric Surgery (ASMBS) estimated that the mortality rate for bariatric surgery after 30 days is about 0.13% — or one in 1,000 people. The ASMBS also states that this mortality rate is lower than other operations, such as gallbladder and hip replacement surgeries.

Bariatric surgery’s benefits far outweigh the risks. Surgery can increase life expectancy by up to 89%, according to Insure.com’s 2021 report. And after surgery, patients fare far better than they would have without it.

Obesity-related issues that are often improved as a direct result of the surgery:

• High blood pressure
• Sleep apnea
• Asthma
• Breathing disorders
• Arthritis
• Cholesterol abnormalities
• Gastroesophageal reflux disease
• Fatty liver disease
• Venous stasis
• Urinary stress incontinence

Bariatric surgery encompasses operations on the stomach, such as:

• Gastric bypass (open and laparoscopic)
• Laparoscopic adjustable gastric banding
• Biliopancreatic diversion

These procedures dramatically restrict one’s ability to eat, thereby causing weight loss. Those who undergo these procedures wind up with a smaller stomach that’s able to hold only a few ounces. Eating too much can make that person feel ill.

In addition, some weight-loss surgeries alter the digestion process, limiting the absorption of calories and nutrients.

You’ll likely also take part in nutritional and behavior classes to help you with the surgery and life after the surgery. 

Requirements for weight-loss surgery

Bariatric and gastric bypass surgery aren’t for everyone. You need to meet certain criteria to be considered a candidate. 

Mayo Clinic said people who are typically eligible for weight-loss surgery:

• Have been unsuccessful in losing weight after improving diet and exercise
• Have a BMI of 40 or higher
• Have A BMI of between 35 and 40 and weight-related health problems, such as type 2 diabetes and high blood pressure

If your BMI is under 35, you may still be eligible if your weight is leading to major weight-related health problems. 

Dr. Richard A. Perugini, a surgeon based in Worcester, Mass., said it’s not always the numbers that make a person decide to have the operation.

“The onset of medical conditions, especially type 2 diabetes mellitus, are common triggers. Bariatric surgery is probably the most powerful tool to treat diabetes. It leads to improved quality and duration of life. For others, the goal is to live a more active life, perhaps to play with children or grandchildren,” he said.

Perugini stressed, however, that not all people who want the surgery get approved. His hospital screens individuals to see if they’re eligible. That includes checking with the individual insurer’s criteria for surgery and behavioral health evaluations.

“We try to be attuned to social support structures. Some medical conditions, such as cirrhosis, serious cardiac or pulmonary disease, require a thorough evaluation and treatment prior to performing bariatric surgery,” he said.

How to get bariatric surgery covered by insurance

In certain situations, your health insurance may cover the cost of bariatric surgery. In addition, some states are required to cover bariatric surgery if you have an ACA-compliant health insurance plan through the Marketplace.

However, weight loss surgery is not automatically covered by every policy and for every person. If you want to get your health insurance provider to cover weight loss surgery, here’s what you need to do:

1. Check the details of your health insurance policy: The first step is to review your policy details to see if bariatric surgery is a covered procedure. You also can contact your insurance company and speak with an agent, who can walk you through the fine print of your policy and what’s covered.
2. Find a surgeon who is in your network: Next, you’ll want to choose a surgeon who is in your health plan network. Depending on your plan, a portion of the cost may be paid for if you visit an out-of-network provider. However, because bariatric surgery can be very expensive, seeing an in-network doctor will likely reduce your out-of-pocket cost significantly.
3. Determine if you qualify for the procedure: If your health plan does cover weight loss surgery, you will need to have your surgeon determine whether you qualify. “Health plans that provide bariatric coverage will usually have specific requirements to be approved for bariatric surgery,” says Dr. Shawn Garber, founder and director at New York Bariatric Group. “This may involve consultations, clearance documentation, or even a history of a medically supervised diet program.”
4. Ask your surgeon to confirm with your insurance provider: As a last step, your surgeon may need to confirm with your insurance carrier that you are a good candidate for the procedure before you get confirmation that your plan will cover the surgery cost. Depending on the type of procedure the surgeon recommends, it may change how much of the cost will be covered by insurance, and how much you will have to pay out-of-pocket. 

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 (EBH) with every Marketplace health plan:

• 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
• Wyoming

How much does weight-loss surgery cost? 

The average bariatric surgery costs $17,000 to $26,000, according to the ASMBS. Mounting evidence shows that surgery for morbid obesity can be more cost-effective than treating the conditions resulting from obesity. However, your health insurance might not pay for the surgery even with your doctor’s recommendation.

The exact cost differs by surgery and your circumstances. However, ASMBS estimated that the surgery usually leads to lower healthcare costs and improved worker productivity, so health plans usually approve the surgery if you qualify.

Will health insurance pay for bariatric surgery?

Health insurers generally pay for bariatric surgery if you meet the requirements.

ASMBS said the most common reasons patients don’t undergo laparoscopic gastric bypass surgery are insurance denial and not getting pre-authorization before the procedure. Insurers deny about 25% of patients considering bariatric surgery three times before approval. If you’re considering bariatric surgery and want your health insurance to pay for it, you may have to jump through a few hoops.

Perugini, though, said don’t let insurance scare you away from the procedure.

“In the vast majority of cases, insurance covers bariatric surgery. Contact your insurance carrier to determine if elective bariatric surgery is a covered benefit through your plan,” he said. “And if your case is denied by insurance, there is an appeals process.”

Know your policy’s terms before scheduling bariatric surgery. Is obesity surgery specifically excluded from your policy? Do you need pre-authorization?

Your insurer will likely require a full medical work-up along with the pre-authorization request. They’ll also probably want to document physician-supervised weight-loss attempts. Insurers rarely cover weight-loss programs; programs like Weight Watchers and Jenny Craig don’t count.

You’ll find out exactly from your insurer what documents you request a pre-authorization. Insurers demand pre-authorizations for many procedures and tests. Regardless, expect it to involve volumes of paperwork. Your doctor will help you and may even work with the insurer to get approval.

Coverage for weight-loss surgery varies widely, as do insurers’ definitions of “medically necessary.”

Does Medicare cover bariatric surgery? 

Medicare covers some weight-loss surgeries, including laparoscopic banding surgery and gastric bypass surgery. 

You need to meet requirements and be deemed severely obese. You and your doctor need to get pre-approval for weight-loss surgery.

Similar to other insurers, Medicare will likely require a BMI of at least 35, your weight must also be causing serious health issues and you’ve attempted for years to lose weight through diet and exercise. 

 

How long does it take Medicaid to approve weight-loss surgery?

If you meet the criteria, Medicaid also allows weight-loss surgeries, but recent studies show approval can 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 to do if you get declined for bariatric surgery

Even if your policy covers bariatric surgery coverage, brace yourself for a possibly long claims process. At best, you’ll need mounds of documentation to show the surgery is medically necessary for you.

Or you may run into big roadblocks. For CIGNA, the main reason for denials is that the insurer doesn’t believe the member met the necessary criteria. In other instances, an employer may not include bariatric surgery in its plan.

If your plan doesn’t exclude coverage and you’re denied, appeal it. You will probably need to provide further documentation of your need for the surgery as medically necessary.

All health insurance plans should have a clear appeals process. Find out what it is and follow directions. You may only have a limited time from the date you were denied or had the procedure to get an appeal underway, possibly only 60 days. Depending on your plan’s procedure, you might have to start with a phone complaint and then move to a written appeal.

CIGNA said if a customer has coverage, but medical necessity was not met and a denial was issued, a medical necessity appeal is available to the member or provider. The denial letter would provide the contact information and instructions to initiate the appeal.

If you’re thinking about appealing:

• A good place to start is your company’s human resources department if your insurance is through your employer. HR can check to see whether the policy actually covers the surgery and could contact the insurance company.
• If you go through with the appeal, talk to your physician and collect any information that will help your case. For instance, ask your doctor for a letter about why the surgery is needed. Some bariatric surgeons even have appeals experts on staff who have experience in getting claims paid after denial. Collect any medical records that may help. Think about your family’s medical history.
• Craft a letter focused on the decision and why the insurer should reconsider. Keep it to the facts. Don’t get into any emotional reasons why the insurer should approve.
• Keep meticulous records of your contact with the insurer and your appeal.
• If it’s denied again, see if there’s a second appeal process or an external appeal.
• If you still get denied, contact your state Department of Insurance. The departments have staff people who help consumers with denials.

If you’ve tried everything and you’re still getting denied, there are a few other options:

1. If your HMO plan doesn’t cover obesity surgery, change to a PPO plan at open enrollment if the PPO plan covers it.
2. Change to your spouse’s plan if it provides coverage.
3. Get a new job. Certain large employers cover weight-loss surgery as a commitment to employee health.
4. Consider paying out-of-pocket and ask your surgeon’s office about payment plans. According to the ASMBS, there are also loans available.

Perugini had some advice for those on the fence.

“Bariatric surgery is a powerful tool. The biggest piece of advice I can give is that long-term success is due to healthy habits. We all have to employ healthy habits. This goes for patients and for practitioners who work in the weight center. We need to plan well to eat frequent meals. We need to eat good quality food. We need to be active.

“However, I feel the most important thing about making healthy habits a lasting part of our lives is that they should feel good. We, as humans, do not do well with deprivation. We should be able to savor our meals. Exercise should be an experience that makes us feel good and that we look forward to. And if and when life gives us particularly stressful challenges, it helps to have a support system to rely on,” he said.

–Elizabeth Rivelli contributed to this report.

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