Many people want to know what they need to do to get insurance approval for gastric sleeve surgery.
Gastric Sleeve surgery is increasingly becoming an important option for people who would like to undergo weight loss surgery. An increasing number of insurers are covering some costs and in other cases all associated expenses of the procedure.
The average cost of the procedure is $15,000 and more.
Popular Insurance Companies Covering Gastric Sleeve Surgery
Insurance coverage varies by the insurance provider and state. Insurers who currently cover gastric sleeve surgery include Emblem Health, Cigna, Aetna, Priority Health, Medica, HealthNet, United Healthcare, Health Care Service Corp and some Blue Cross-Blue Shield programs.
In the case of government health plans, Medicare does not currently cover gastric sleeve surgery for everyone, and with Medicaid, only a few states cover the surgery. One exception is the state of Virginia whose Medicaid’s program refers patients for bariatric surgery.
In the case of government health plans, Medicare does not currently cover gastric sleeve surgery for everyone, and with Medicaid, only a few states cover the surgery. One exception is the state of Virginia whose Medicaid’s program refers patients for bariatric surgery.
What Is Covered?
The insurance scope for gastric sleeve surgery is similar to the coverage of other bariatric surgeries. Insurers usually include the surgeon’s fee, hospital facility fee, and the anesthesia fee.
Some insurers foot the entire bill, but many only pay 80% of what is considered as the usual and customary cost of the procedure. Usual is defined as the normal rate of the service as charged by the provider and customarily refers to the usual rates of the competitors in that particular location.
Other employers or insurance companies may require the insured to co-pay a certain amount of up to $5,000.
Some items that insurers don’t normally cover include surgeries to remove excess skin such as face lift, tummy tack, bra-line back lift, breast lift, liposuction or any other plastic surgery procedure after a weight loss surgery.
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Requirements
Medicare Pre-approval Requirements
- BMI of 35 or more.
- Documented evidence of obesity for the last five years.
- A minimum of one obesity-related health complication such as diabetes, apnea, high blood pressure, etc.
- Documented evidence of participation in a medically supervised weight loss program. Proof that you participated and failed in more than one program.
- A letter is recommending weight loss surgery from your physician.
- Successfully passed a psychological evaluation.
- Any treatable medical diseases have been ruled out as a probable cause of your obesity. Screening tests for thyroid, pituitary, and adrenal are standard.
Medicaid Pre-approval Requirements
- BMI of 35 or over with at least one obese-related health complication such as sleep apnea, high blood pressure, diabetes, etc.
- Must be 13 years and over for a female and 15 years and over for a male.
- For persons under the age of 21, you must have a BMI of over 40 with at least one obese-related health complication.
- Successfully passed a psychological exam.
- Evidence documentation is showing participation in a medically supervised weight loss program for six months and within the last 12 months before surgery.
- Documentation showing attempts at managing obese-related health complications with standard treatment but unsuccessful.
- Letter from your physician supporting and recommending weight loss surgery as necessary.
- Availability of psychological and nutritional services before and after surgery usually at the doctor’s office.
- A willingness by the patient to change diet and lifestyle after the weight loss surgery.
You may however not qualify for weight loss surgery in the event of the following circumstances:
- Cancer.
- Long-term steroid use.
- Inflammatory bowel disease, pregnancy or non-compliance with medical treatment.
- Psychological treatment which could interfere with post-surgery diet and lifestyle requirements.
Private Insurance Companies’ Pre-approval Requirements
Most insurance companies cover gastric sleeve surgery upon documentation from your local doctor that the procedure is medically necessary. A letter of medical necessity is a requirement for your weight loss surgeon and should contain:
- Your weight history, height, and BMI.
- Your current medications.
- A detailed description of obesity-related health complications and treatment records.
- A detailed description of how obesity affects your daily activities.
- Documentation evidence is showing past weight loss attempts including evidence showing participation in a medically supervised weight loss program accompanied by six months notes from the supervising doctor.
- Documentation of exercise programs including gym membership.
Process for Insurance Approval for Gastric Sleeve Surgery
- Your doctor needs to confirm minimum BMI i.e. over 35 with an obese-related health complication.
- Schedule and complete a medically supervised weight loss program lasting 6-12 consecutive months.
- Meet with health care professionals and obtain the necessary paperwork which includes an overall assessment by your bariatric surgeon, a letter of medical necessity, a psychiatric evaluation and mental health clearance letter and a nutritional evaluation and post-surgery eating advice from a registered dietician.
- Include evidence documentation of previous weight loss attempts such as gym membership, FDA-approved weight loss supplements.
- Forward all these documentation to your insurance company for review. This typically takes a month.
- Approved applicants will get an approval letter which they can use to schedule their surgery.
- Denied applicants can initiate an appeal process by writing an appeal letter.
