For patients that are struggling with their health due to their weight, bariatric surgery can provide hope for an improved quality of life. However, different insurance companies and policies cover different things. So, how can you get insurance approval for weight loss surgery?
Become Informed on Weight Loss Procedures
You will want to not only be informed on your own insurance policy, but also the health plans that surround weight loss procedures. Speak with your primary care provider, as well as specialists and surgeons, to learn all you can regarding your health. This can help you fully understand what your weight loss journey will entail, as well as the procedure that your surgeon has recommended for your own unique situation. If you have any questions or concerns regarding your weight loss procedures, have a conversation with your surgeon.
How to Get Insurance to Pay for Bariatric Surgery: Demonstrating Medical Necessity
In order for insurance to grant coverage for weight loss surgery, patients will need to demonstrate some level of medical necessity. This expands further than a consultation with your insurance provider, as you will need to also provide documented evidence. However, this criteria can vary from insurance provider to insurance provider.
You will likely have to meet some or all of the following criteria in order to get weight loss surgery covered by your insurance.
You may be able to have insurance cover your procedure if you are:
- Are over the age of 18
- Have a diagnosis of morbidly obese
- Have a BMI of 40 or greater or have a BMI of 35 or greater with a comorbidity
- Are not a smoker
- Have a documented record of prior weight loss efforts
Pass a Psychological Evaluation
Some insurance providers will require patients to pass a psychological examination to rule out any underlying mental health concerns. This is to ensure that patients have a reasonable expectation for their procedure and helps to support long term success of the patient’s overall health. The psychological exam will cover the patient’s weight history, eating behaviors, and psychiatric history.
Provide Proof of Weight Loss Attempts
In general, insurance companies will require patients to submit evidence of prior attempts to lose weight. This may include following a doctor’s recommended plan for weight loss or engaging in the insurance provider’s developed program.
Typically, insurance providers require these substantial efforts to last at least around three to seven consecutive months. Documentation may also need to be provided that details the patient’s exercise routine and dietary regimen to get approval.
Tips to Get Bariatric Surgery Covered by Insurance
In some instances, your insurance may cover the cost of weight loss surgery. If you are located in a certain state, your state may be required to cover weight loss surgery if you have an ACA-compliant plan through the Marketplace. However, this does not mean that weight loss surgery is automatically covered through all plans. If you want to get your insurance to cover bariatric surgery, you should:
Check your Health Insurance Policy
Look into your health insurance policy on your own to see if bariatric surgery is covered. If you are having difficulty navigating your policy or have questions, you can also contact an agent that works for your insurance company. They can help you understand what your policy covers.
Find a Surgeon in Your Network
Choose a surgeon that is in your network. Visiting a surgeon that is within your network could help you save on out-of-pocket costs.
Determine if You Qualify
If your health plan does cover weight loss surgery, you can ask your surgeon to determine whether you qualify and to review your policy.
Ask your Surgeon to Confirm with your Insurance Provider
Your surgeon may need to confirm with your carrier that you are a match for weight loss surgery before you are able to get approval. Your surgeon has different options for procedures that they could recommend to you. Depending on what they choose for your own unique situation, the price you pay out-of-pocket and what is covered by insurance could vary.
States Where Insurance is Required to Cover Weight Loss Surgery
Under the Affordable Care Act’s Essential Health Benefits Benchmark Plans, these states require that all individual, family, and small group insurance plans cover bariatric surgery.
- 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
What if I’m covered by Medicare or Medicaid?
To get approved, you’ll need to be referred by your primary care physician or other healthcare professional. Medicare and Medicaid both cover bariatric surgery. However, you will need to meet their guidelines for coverage.
- A BMI over 35
- At least one comorbidity related to obesity
- Documentation confirming that previous attempts at medical treatment for obesity have failed
I Was Denied by my Insurance, Now What?
Every day, individuals are denied bariatric surgery. While being denied access to weight loss surgery can lead individuals to feeling hopeless, there are still options available.
The first step is to become educated on weight loss surgery and perhaps connect with patients that underwent the procedure. These peers can provide you with valuable information and even resources. Become an advocate for your health and speak openly about how your weight, as well as not receiving access to care, has affected you.
If you were denied, you could consider:
- Speaking with your human resources department at your employer. Is your employer self-insured? Find out if you meet their criteria. Work with your surgeon to complete a peer-to-peer review if your company covers surgery and you meet the criteria.
- Hiring an advocate. This might be a lawyer who specializes in representing individuals affected by obesity.
- Educating yourself and others using the methods that were mentioned in this article.
- Consider an alternative options including:
- Opting for affordable self-pay bariatric surgery in Mexico
- Getting Financing for Bariatric Surgery
- Apply in Future, after meeting criteria
- Change your Health Insurance
If your employer is self-insured and they don’t have a bariatric surgery benefit, you can view this fact sheet created by the Obesity Action Coalition. This fact sheet is designed to share with employers and insurance providers.
