Insurance Coverage for Weight Loss Surgery: Bariatric, Gastric Sleeve

Many health insurance plans provide some coverage for bariatric surgery. Gastric banding, sleeve gastrectomy, and gastric bypass are considered safe and effective treatments for obesity. But, before coverage, surgery can cost $15,000 to more than $25,000. How does insurance cover weight loss surgery? This article answers some common questions about medical criteria and how insurance companies can help with medical costs.

Will insurance pay for weight loss surgery?

Most insurance plans, including Medicare and Medicaid, cover weight loss surgery if you meet medical criteria. Plans vary regarding which surgeries are covered and how much.

Health insurance plans vary by company; weight loss surgery benefits can differ by state and policy type. A private plan may be fully insured or self-funded, like an ASO (Administrative Services Only), and it’s essential to be aware of any possible exclusion language for bariatric treatments.

Insurance companies must approve the surgery before honoring coverage. You will be responsible for any deductibles, co-insurance, and copay fees. Bariatric surgery approval is a process, and it’s important to remember there can be additional out-of-pocket costs for testing, counseling, inpatient hospital stay, and follow-up appointments.

Most insurance plans provide coverage for revisions due to complications. So, if you require another surgery to repair a complication, insurance may need another pre-certification for additional surgery. Some plans may review these on a case-by-case basis.

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Types of weight loss surgeries covered by insurance

Obesity puts people at risk for serious health conditions. Weight loss surgery can help manage overall well-being and quality of life. These procedures are appropriate in treating obesity when exercise and diet are unsuccessful. It can also benefit people suffering from serious medical conditions associated with obesity when other treatments have failed.

Different types of bariatric surgeries are available. Generally, procedures can involve decreasing stomach size and manipulating the digestive tract. Shrinking the stomach limits the amount of food needed to feel satiated. Dividing, rerouting, or changing the path of the digestive tract (intestines) means the body absorbs fewer nutrients, resulting in weight loss.

Bariatric surgery is a broad term that includes all weight loss surgeries. A bariatric surgery candidate typically has a body mass index (BMI) of 35 or more.

The following is a list of the most common bariatric procedures generally covered by most insurance plans (such as BCBS, Aetna, and others):

Gastric sleeve surgery

Known as a sleeve gastrectomy. This procedure is permanent and involves removing about 80% of the stomach. The remaining portion is about the size and shape of a banana. Since the stomach is smaller, it limits the amount of food ingested.

Lap band surgery

Known as gastric band surgery or laparoscopic adjustable gastric banding. This procedure has decreased in popularity over recent years. The LAP band procedure makes the stomach smaller by placing a ring around the top part of the stomach and dividing it into two sections. It is reversible, and it does need adjustments after placement. Making the stomach smaller makes you feel full with less food.

Gastric bypass surgery

Known as Roux-en-Y gastric bypass. Roux-en-Y means in the shape of a “Y.” This procedure works by permanently dividing the stomach, leaving a smaller stomach, and dividing and diverting the intestines to create a bypass. Food enters the small stomach and bypasses the unused part of the stomach and part of the intestines. It works by limiting the food ingested and decreasing absorption.

Biliopancreatic diversion with duodenal switch

Abbreviated as BPD/DS, it is another complex procedure beneficial for certain types of situations. It is permanent and involves shrinking the stomach like a gastric sleeve, surgically removing a large part of the stomach. The intestines are divided into two tracts and reattached to allow food to bypass a large portion of the intestine. This procedure has more complications, including malnutrition and vitamin deficiencies.

What insurance covers weight loss surgeries?

Insurance coverage varies by the health plan, policy type, and state of residence. Under the Affordable Care Act essential health benefits, states could decide what their plans would cover for bariatric care. Twenty-three states included bariatric care in all individual, family, and small-group plans.

No one specific type of plan covers weight loss surgery. You could be eligible for bariatric surgery if you have a Preferred Provider Organization (PPO), Health Maintenance Organization (HMO), Exclusive Provider Organization (EPO), Point of Service (POS), Medicare, or Medicaid. However, some plans or employers can place limitations on services.

The initial step is determining if your plan has a bariatric surgery policy and how to qualify. Most plans have internal medical policies with detailed criteria information. A medical policy should provide clear coverage criteria for weight loss procedures.

Contacting your plan representative for more detailed, accurate, and up-to-date information is helpful. You can request a Summary of Benefits and Coverage at any time.

You can search online for your health insurance medical policy. It may be on the website or an account portal. Companies periodically make changes and update their policies, so having the most updated version is critical when working toward pre-certification.

Remember that choosing in-network or out-of-network services can affect coverage. Some insurers require bariatric beneficiaries to get care at a Center of Excellence (COE). Bariatric COEs have a proven track record for high-quality care and better patient outcomes. Coverage may be limited to COE programs.

After weight loss surgery, body contouring procedures reduce excess fat and skin. However, some carriers may consider it cosmetic and not medically necessary. Coverage will depend on individual plans and reasons for the procedure.

Understanding the criteria for insurance coverage

A recent study of 64 American health insurance providers found that most plans have medical policies for the four main types of bariatric surgery.

Insurance companies use guidelines called medical policies when comparing a person’s medical records against set criteria. Each company will have internal medical policies based on national standards and care guidelines. Insurance companies also use evidence-based screening tools like InterQual and Milliman to guide determinations on medically necessary criteria and appropriate levels of care.

A preauthorization or precertification review of medical records will determine approval. Insurance companies review medical records, comparing them to policies to make final clinical determinations.

You could qualify for weight loss surgery if:

• You are over 18 years of age with a BMI between 35-39.9 and have medical conditions related to obesity
• You are over 18 years of age with a BMI of 40 or greater
• You have participated in a supervised weight management program
• Had a nutritional evaluation
• Had a psychosocial evaluation
• Do not have substance use disorders
• Do not smoke or have completed a smoking cessation program

Recently, adolescents and young adults have qualified for weight loss surgery, but the criteria are usually different for people under 18, and not all plans cover this benefit.

How to get weight loss surgery covered by insurance: step-by-step guide

When choosing a bariatric surgeon, comply with any insurance requirements for Centers of Excellence and In-network providers. All bariatric surgeries permanently alter the gastrointestinal system except for gastric banding. However, medical criteria and the pre-certification process are typically the same regardless of procedure.

Many bariatric centers offer specialized processes, guiding people through initial education seminars to after-surgery care. They may have nutritionists, psychologists, and social workers on staff. To help better understand the process, the following is a typical step-by-step guide of what to expect when getting insurance coverage for any of the four most common weight loss procedures.

1. Complete an evaluation with a bariatric surgeon. Your doctor will take a thorough health history, answer questions, make recommendations for surgery, and establish a care plan.
2. Complete an education seminar. As a potential bariatric surgery candidate, your provider may require you to attend an information session about the process, surgery, and long-term considerations.
3. Provide an updated copy of your insurance to your provider’s office. To avoid delays, provide an updated copy of your insurance coverage to your provider’s office. Inform appropriate office staff of any changes to your insurance coverage immediately.
4. Complete a weight loss management program. Your doctor and insurance provider want you to participate in a comprehensive nutrition, diet modification, and exercise program. Insurance may require your participation for several months before determining success.
5. Complete psycho-social screening. Screening helps determine if you are mentally ready for weight loss surgery and have support systems in place.
6. Complete a smoking cessation program if you are currently using tobacco products. Smoking can affect the body’s ability to heal, and you may need to quit smoking before seeking approval. Additionally, active substance and alcohol addictions can make someone an unsuccessful candidate for weight loss surgery.
7. Complete any additional testing or referrals timely. You may need to complete testing like a sleep study to support a diagnosis of comorbidities. Additionally, your doctor will order pre-op testing, including blood work.
8. Get approval from the bariatric team. A bariatric surgeon is part of the larger team evaluating your readiness for surgery. Bariatric surgery is a big decision; they must confirm you are a good candidate before submitting anything to insurance.
9. Submitting paperwork to insurance. Once the bariatric team approves, the physician’s office will submit the paperwork to insurance for pre-authorization or pre-determination. Your doctor’s office will typically gather and submit all medical records. Usually, an office staff on the surgeon’s team (called a surgery scheduler) will liaise with insurance on your behalf. Once the pre-authorization request is submitted, insurance will review all the information and decide. Insurance will notify your physician’s office. Insurance decisions could take a few days to a few months.
10. Scheduling surgery. If your request is approved, then surgery can be scheduled.
11. A note about denials or non-approvals. A request for pre-authorization can be delayed if something is missing from the paperwork. Often, once the missing clinical is submitted, approval is issued. Alternatively, if insurance denies your request because you do not meet medical necessity, peer-to-peer processes may allow your doctor to plead the case for reconsideration. You also have appeal rights; your physician’s office can likely help you with that process. There may be a time frame for appealing.

If you are considering weight loss surgery, most insurance plans will help cover costs once you meet medical criteria. The health benefits of bariatric surgery are numerous. By committing to long-term lifestyle changes supported by surgery, people can live longer, healthier, and more active lives.