How to Know if Insurance Will Cover Weight Loss Surgery

Posted by Jason Radecke on Tue, Nov 13, 2012

Even if you and your doctor have determined that bariatric surgery is right for you, financial concerns may halt some candidates for bariatric surgery from continuing on their weight loss journey. While bariatric surgery can create huge health improvements for some patients, it can also be costly. Getting insurance coverage for bariatric surgery could be the deciding factor on whether or not they’ll have bariatric surgery.

Unfortunately, figuring out your insurance coverage can be tricky and dealing with insurance companies can be a nightmare. They’re notoriously difficult to work with. Here are some things to consider as you get in touch with your insurance provider and work out the cost of your bariatric surgery.Insurance Coverage

How much does bariatric surgery cost?

Bariatric surgery can cost anywhere between $17,000 and $30,000, though self pay prices are generally lower--around $13,000. The cost of bariatric surgery varies based on the type of surgery you’ll have and where you’ll have your procedure performed.

Contacting your insurance company.

Insurance coverage varies by state and insurance provider. Depending on your insurance agency and plan, they may offer full, partial, or no coverage. If you’re considering bariatric surgery, you should first call your insurance company to find out if they offer coverage for bariatric surgery. If they do, ask them which surgeries they will cover. Many private insurance companies provide coverage for the gastric lap band surgery. Once you know that your surgery is applicable for coverage, find out what percentage of the bill you may be expected to pay, and if there is a deductible.

Many private insurance companies request a variety of documents in order to pre-approve policy holders, so once you know what’s covered, you’ll want to get that process moving. You’ll need to work with your weight loss center to have the proper documents sent to your insurance company. These documents will help them assess if you meet the requirements within your policy. After either you, or your weight loss center, have sent over these documents, you’ll want to follow up with your insurance company to make sure they’ve received all the information they need to begin your pre-approval.

Know the requirements.

Insurance companies will typically have a long list of requirements you must meet before you can get coverage for bariatric surgery. One requirement you can consider early on is your choice of weight loss center. Many insurance companies, including Medicare, require that patients undergo their surgery at a bariatric surgery center that has been designated as a Center of Excellence by the ASMBS. This designation shows insurance companies that the surgical center has performed at least 125 surgeries, that the surgeon performs at least 50 surgeries a year, and with other requirements which indicate an experienced, safety focused surgical center.  

Other important requirements may include:

  • Diagnosis of morbid obesity.
  • Body mass index (BMI) of greater than 40, or a BMI greater than 35 in combination with co-morbidities such as diabetes or sleep apnea.
  • Participation in a physician-supervised weight loss program for extended time periods (this can vary from 3 to 12 consecutive months, depending on your insurance plan).
  • Documentation of failed diet and exercise plans.
  • Letter of medical necessity from your doctor.

Depending on your insurance plan, you may need to meet additional requirements.

If you’re denied coverage.

If your request for coverage is denied, it doesn’t mean you still can’t get coverage, but you’ll need to start asking questions. Ask your insurance company why you were denied coverage and how you can file an appeal. You’ll want to start the appeals process quickly, as it can be tricky and lengthy. Your bariatric surgical center may also be able to help you navigate the appeals process. Once you’ve filed your appeal, make sure to follow up with the insurance company to make sure they’ve received it.

If all else fails and you’re still denied coverage, your weight loss center may be willing to work with you to make your surgery as affordable as possible through payment plans.

Applying for and getting insurance coverage for bariatric surgery can be a hassle, but practicing communication and persistence while dealing with your insurance company will be extremely helpful during this process. If you ever feel lost, don’t be afraid to ask for help. Riverside Surgical and Weight Loss Center has a bariatric insurance coordinator on staff who will be able to help you coordinate coverage with your insurance company.

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Tags: Weight Loss Surgery Covered by Insurance

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