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Does Health Insurance Cover Weight Loss Surgery?

Most major insurance companies offer some form of coverage when it comes to weight loss procedures, including gastric bypass, gastric sleeve and lap-bands. While many plans have begun covering these surgeries, it’s important to do your research on which carriers do and do not offer assistance.

Weight loss procedures and insurance coverage

Insurance providers make a distinction between bariatric procedures that are included in your coverage (required for your health) and those that are considered elective treatments (not necessary for your health). Typically, but not always, insurance companies may cover gastric bypass, gastric sleeve, and lap-band procedures.

Other procedures such as gastric balloon are considered to be experimental and, like abdominoplasty procedures, are not covered at this time. Some special plans may be exceptions to the rule, and the best way to check is to speak to your insurance agent, insurance company representative or human resources officer at your job.

What Is Covered?

Insurance coverage for gastric sleeve tends to be similar in scope to coverage of other bariatric surgeries. Insurers usually cover the anesthesia fee, hospital facility fee and the surgeon’s fee. Some insurers may pay the entire bill, but others only pay 80 percent of what is considered “usual and customary” for gastric sleeve surgery. “Usual” refers to the normal rate charged for the service by the provider rendering the treatment, and “customary” is defined as the usual rates of the provider’s competitors in that local area. The usual and customary rate differs for every situation and is determined by the insurance company. Some insurance companies or employers may also require a co-pay which can range from a small amount to up to $5,000.

If you are considering gastric sleeve, contact your insurance plan to find out if the procedure is covered, and what such coverage entails. For example, insurance often will not cover body contouring surgeries to remove excess hanging skin, including corset trunkplasty, bra-line back lift, facelift, breast lift, tummy tuck, liposuction or any plastic surgery procedures which you might want to have after your dramatic weight loss.

Gastric sleeve insurance coverage may include the program elements that are necessary to be successful with your procedure such as support groups, exercise and nutrition counseling.

Criteria Varies by Insurer

Insurance carriers cover the cost of gastric sleeve if you meet certain pre-specified criteria, which vary by company. Most insurance companies/employers that offer gastric sleeve insurance coverage require a body mass index (BMI) equal to or greater than 40, or a BMI of 35 if there are significant medical problems associated with your weight, like Type 2 diabetes, sleep apnea and heart disease. A BMI of 40 or above is the equivalent of being about 100 pounds overweight for men and 80 pounds overweight for women.

Disparities in coverage are common. Some insurance companies may cover the cost of surgery for individuals with a BMI of 40 or higher, or a BMI 35 to 39.9 and one obesity-related illness. Other insurers have significantly higher BMI requirements because they have not updated their requirements to include the gastric sleeve as a standalone, primary bariatric surgery procedure. For example, one insurance company may require a BMI of 60 or higher for coverage. If a person has severe heart and lung problems associated with obesity, however, they may lower the BMI requirement and cover the costs of surgery. Once the patient has undergone the procedure and loses a significant amount of weight, he or she then goes on to have another bariatric procedure like duodenal switch or gastric bypass to complete the process. Insurance may cover the costs of the second procedure.

Action Points

Many private insurers will require a “letter of medical necessity” from a surgeon before they agree to pay for your gastric sleeve surgery. The letter should include information on your height, weight history and BMI, a detailed description of your obesity-related health conditions, your current medications and a detailed description of how obesity affects your daily activities.

Be proactive where you can. Start collecting letters and documentation from all health care professionals who have treated you for obesity-related problems now. Keep detailed records of all your weight loss attempts.

Contact us today a complimentary insurance verification. Call 305-821-3795 or contact us here. We will contact your insurance company on your behalf, after your FREE consultation.