Is Bariatric Surgery Covered by Insurance?

November 08, 2021 Bariatric Surgery

Alleviating the conditions of morbid obesity may require more than regular exercise and a balanced diet. In such times, bariatric surgery can be your best bet.

However, for obese patients who qualify for a weight loss surgery, one of the biggest concerns is – “does insurance cover my bariatric procedure?”

Bariatric surgery is a costly weight loss procedure. The average cost may range between $15,000 and $35,000 across all types of bariatric surgeries in the U.S. The costs are substantially higher even in Canada, Australia, and New Zealand. For any average-income person, paying for the procedure out of their pocket can be considerable. As such, health insurance seems to be a viable option to fund one’s bariatric procedures.

Earlier, most insurance companies did not cover weight loss surgery in their health plans. But with the growing prevalence of bariatric surgery in recent times and even the federal government approving the procedures, many carriers have started to include weight loss surgery in their coverage plans.

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 what’s covered and what’s not.

What’s Covered in Insurance?

If you are lucky to have an insurance plan that covers bariatric procedures, then it is likely you’d want to know what’s covered in the policy. This may vary depending on your policy type, insurance company, or how much you pay for the coverage. Typically, a health plan will protect your finances by providing a wide range of benefits that include:

• Cashless hospitalization at any network bariatric center or hospital
• Daily allowances
• Coverage for pre-and post-hospitalization medical expenses
• Alternative treatment if required
• Ambulance cover
• No claim bonus

However, there are certain eligibility criteria that you must fulfill to get coverage for your bariatric surgery. Most insurance companies need the individuals to meet the following conditions:

• The insured must be 18 years old or above
• The bariatric procedure is prescribed by the doctor
• BMI of the insured is more than or equal to 40
• Or the BMI is greater than or equal to 35, but the individual has severe comorbidities like coronary heart disease, sleep apnea, cardiomyopathy, or Type 2 diabetes that require less invasive weight loss methods

Insurance Companies that Provide Coverage for Bariatric Surgery

Today, many insurance carriers provide health plans covering various types of bariatric procedures. In this article, we will discuss the popular ones based on some important criteria. Let’s get started.

Aetna

Aetna is a leading insurance provider that covers most bariatric surgeries, except Aetna QPOS and HMO plans that exclude all obesity-related surgical procedures unless otherwise approved by the carrier. To qualify for insurance coverage, patients must meet the following criteria:

• Adults aged 18 years or older or adolescents aging 13 years (girls) and 15 years (boys)
• For adults, BMI exceeding 40 or BMI more than 35 but with any of the following comorbidities such as:
• Obstructive sleep apnea
• Type 2 diabetes mellitus
• Coronary heart disease
• Medically refractory hypertension
• For adolescents, BMI exceeding 40 or 50 with one or more serious/less serious comorbidities as mentioned on the official website of Aetna
• The patient has participated in a weight loss program in the past, but without long-term outcomes
• He/she must fulfill either Criterion 1 (physician-supervised exercise program and nutrition) or Criterion 2 (regimen for multi-disciplinary surgical preparation)

Bariatric procedures that are covered by Aetna include:

• Open or Lap Gastric Bypass (Roux-en-Y)
• Lap Gastric Sleeve or Sleeve Gastrectomy
• Lap Gastric Bands, including Lap Band or Realize Band surgery
• Duodenal Switch

Roux-en-Y gastric bypass surgery, performed for the treatment of gastroesophageal reflux in non-obese patients, is not covered under Aetna health plans. They further do not mention that the surgery must be performed at an institution accredited by the Center of Excellence.

Anthem Blue Cross Blue Shield

Most Anthem Blue Cross Blue Shield policies across the entire network cover bariatric surgery unless and otherwise clearly excluded from the plan. However, your employer might opt-out from including bariatric surgery in employee policies, saving more money for the company on premiums. Therefore, make sure you seek information from the insurance company or contact an agent to learn whether your plan covers bariatric procedures. To get BCBS insurance approval for bariatric surgery, here are some minimum requirements you must meet:

• Minimum 18 years of age; for adolescents, there are special considerations if they have severe obesity conditions and special comorbidities
• A letter from primary care physician
• BMI of 40 or greater
• A Body Mass Index of 35 or greater with a minimum of two comorbidities as mentioned in your policy
• Documentation showing active participation in non-surgical or non-invasive weight loss programs, which indicates you might be the right patient for bariatric surgery
• Documentation validating consultation, recommendation, nutritional, and psychological evaluation from a bariatric surgeon

Various types of bariatric procedures are covered under Athena BCBS plans. These are:

• Gastric Sleeve surgery
• Laparoscopic Gastric Bypass
• Duodenal Switch surgery, known as Biliopancreatic Diversion
• Gastric Banding, including Realize Band and Lap-Band
• Open Gastric Bypass Surgery

Anthem BCBS excludes Banded Vertical Gastroplasty, Mini-Gastric Bypass or other bariatric procedures that are still in the experimental stage. A second bariatric procedure or revisions are also included in the plan if specific criteria are met as mentioned in the policy.

More Information

Cigna

Cigna is another widely popular insurance company that covers weight loss surgery in most types of policies. However, there are ones that entirely exclude bariatric procedures. So, make sure you read your policy carefully or talk to a Cigna insurance agent before buying one. The prerequisites to get approval for insurance coverage include:

• The insured must be a minimum of 18 years of age. For adolescents, he or she must have reached the required skeletal growth
• Evidence showing a Body Mass Index of 40 or higher
  • A BMI between 35 and 40 also gets approved if the insured has at least one of the following significant comorbidities:
  • High cholesterol
  • Type 2 diabetes
  • Pulmonary hypertension
  • Heart disease
  • Obstructive sleep apnea
• Documentation indicating that other medically supervised non-invasive weight loss methods have failed to deliver long-term results. This must include monthly documentation of your weight, exercise program, and nutritional program
  An evaluation from primary care physician and bariatric surgeon recommending that bariatric surgery is essential
  A nutritional and mental health evaluation report from a registered dietician or general physician is also required

Weight loss surgeries that Cigna covers in their policies are:

• Gastric bands, including Realize Band and Lap-Band
• Gastric sleeve surgery
• Gastric bypass
• Duodenal switch
• Vertical banded gastroplasty

One of the basic concerns of an obese patient is – does Cigna also cover lap band fills? Yes, they do cover lap band fills because the insurance company considers it an important weight loss procedure. However, some procedures that are not covered are intragastric balloons, gastric bypass surgery that is combined with a gastric band, loop gastric bypass, Fobi-pouch, or other experimental procedures. Cigna also covers a second bariatric surgery if you can provide evidence that the first procedure has failed to help you lose 50% of excess body weight.

More Information

Medicare

The national health insurance program also covers some bariatric procedures, given you meet the below-mentioned requirements:

• The patient must be at least 18 years of age or an adolescent who has an optimum skeletal structure and has one or more comorbidities
• BMI of 35 or greater and with one or more comorbidities related directly to morbid obesity. These may include high blood pressure, sleep apnea, diabetes, etc.
• Documented evidence that shows you have been suffering from a morbid obese condition for the last 5 years
• A valid letter from your general physician or a weight loss surgeon supporting or recommending bariatric surgery
• Documentation validating your participation in a medically supervised non-surgical weight loss program. The objective is to prove how you have participated in various programs and yet failed every time to get desired outcomes
• Evidence that your obesity condition is not caused due to other medical diseases. Thyroid, pituitary and adrenal screening tests have been done and are normal
• Documentation stating you have passed a psychological and nutritional assessment

Currently, Medicare plans cover the following bariatric procedures:

• Gastric bypass
• Duodenal switch
• Realize Band or Lap-Band surgery
• Sleeve gastrectomy, but is covered only on a regional basis. You can check with a local Medicare administrator or talk to a bariatric surgeon to know if this procedure is covered in your region

Currently, Medicare does not require the surgery to be performed in a facility approved by the Center of Excellence.

United Healthcare

When it comes to getting insurance coverage for your weight loss surgery, United Healthcare might not be a viable option because their Summary Plan Descriptions and Certificates of Coverage outrightly exclude coverage for bariatric procedures. But several plans do cover weight loss surgery. As a matter of fact, certain states make it mandatory for insurance carriers to cover such procedures. Therefore, even if your United Healthcare plan does not cover weight loss surgery, you can still have good luck if your state mandates such coverage.

To get approved for the coverage, you need to meet the following requirements:

• Class II obesity for patients with a BMI greater than 35 and with at least one of the following comorbidities:
  • Cardiovascular diseases like angina, stroke or hypertension
  • Type 2 diabetes
  • Life-threatening cardiopulmonary conditions or severe sleep apnea
• Class III obesity for patients with BMI greater than 40
• Minimum 18 years of age
• Documented proof showing that you have dedicated medically supervised weight loss diet programs, but failed to achieve long-term results. United Healthcare requires you to participate in two structured dietary programs for 3 successive months OR one structured dietary program for 6 successive months

Despite United Healthcare isn’t the best choice to have insurance coverage for your bariatric surgery. But there are several procedures included in their plans that accept weight loss surgery:

• Gastric bypass
• Vertical banded gastroplasty
• Lap adjustable gastric bands, including both Realize Band and Lap-Band
• Duodenal switch
• Biliopancreatic bypass

For adolescents, the following bariatric procedures are covered:

• Gastric sleeve
• Lap gastric bands
• Gastric bypass

If your lap band procedure does not work the first time or a complication arises that requires your further treatment and hospitalization, United Healthcare will also cover the same provided you qualify the criteria.

United Healthcare Bariatric Surgery Requirements

What if Insurance Denies My Claim

There are several options if insurance denies your bariatric surgery claim:

• Make sure all your information you sent was accurate, and reapply
• Wait and reapply

In addition, you may want to consider low-cost self-pay bariatric surgery in Mexico. With low-cost bariatric surgery, you can bypass a lot of the headache of going through insurance and get the surgery on your schedule. You an in addition lower your out-of-pocket expenses by paying directly to a provider in Mexico.

Additional Resources:

1. What to do When You’re Denied Weight Loss Surgery
2. Weight Loss Surgery Insurance Secrets
3. Myths about Bariatric Surgery in Mexico
4. The Best Bariatric Surgeons in Mexico

Conclusion

If you are considering undergoing bariatric surgery, funding it through your insurance plan might be the best option. However, not all health plans cover weight loss surgery. So, it is important to read your insurance policy thoroughly and check what’s included. If weight loss procedures are not covered in your plan, talk to an agent to get it included right away.

If you have an insurance policy from any of the carriers discussed above, the article can be helpful to talk to your agent and discuss what you can get included in the existing plan. For an additional cost, you can upgrade your policy to include weight loss surgery or buy a new plan. According to industry experts, even if your plan does not cover bariatric surgery, you may be lucky to get coverage if the insurance carrier considers the bariatric procedure a medical necessity for your obesity condition.

But before you get an insurance plan, read and understand what all will it cover. It is better to have comprehensive coverage for the weight loss surgery because it is a costly procedure and you may also require post-operative consultation or treatment.

Am I a Candidate?