Haris Ashley
Bariatric surgery is a life-altering procedure that can help individuals suffering from obesity to achieve their weight loss goals and optimise their health. While it is a costly procedure, many insurance companies recognise the serious health threats associated with obesity and do cover weight loss surgery as long as certain qualification requirements are met. This article will explore the steps one should take to obtain insurance coverage for bariatric surgery, the different types of insurance plans that may be available, and the role of medical professionals in the process.
| Characteristics | Values |
|---|---|
| Insurance coverage for bariatric surgery | Many insurance companies recognize the serious health threats of obesity and cover weight loss surgery as long as qualification requirements are met. |
| Medicare coverage | Medicare covers some bariatric surgical procedures, like gastric bypass surgery and laparoscopic banding surgery, when certain conditions related to morbid obesity are met. |
| Pre-authorization | The surgeon will prepare a letter to obtain pre-authorization from the insurance company, establishing the "medical necessity" of the surgery. |
| Insurance company response time | 30 days is the standard time for an insurance provider to respond to a request. |
| Appeal process | If pre-authorization is not approved, insurers provide an appeal process to address specific reasons for denial. |
| Insurance coverage requirements | Requirements vary and may include a medically supervised diet history, a psychiatric evaluation, and documentation of previous weight loss attempts. |
| State legislation | Some states, such as New Hampshire, Georgia, Indiana, Maryland, and Virginia, have laws recommending or mandating that insurers offer coverage for bariatric surgery to treat morbid obesity. |
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What You'll Learn
Insurance companies that cover bariatric surgery
Bariatric surgery is covered by some insurance companies, but the specific coverage varies depending on the company and the policy. It is important to carefully review the terms of your insurance policy and contact the insurance company directly if you have any questions. Here is a list of some insurance companies that have been mentioned as covering bariatric surgery:
Medicare:
Medicare covers some bariatric surgical procedures, such as gastric bypass surgery and laparoscopic banding surgery, provided certain conditions related to morbid obesity are met. However, it is important to note that Medicare does not cover transportation costs associated with bariatric surgery.
Private Health Insurance:
Private medical insurance plans, such as those offered by Better Health Insurance, can provide coverage for weight loss surgery, including procedures like gastric band, gastric bypass, and gastric sleeve. These plans often include initial consultations, necessary tests, hospital fees, and follow-up care. The cost of private medical insurance can vary depending on age, postcode, and cover requirements, but it can be obtained for as little as £44 a month.
UCLA Health:
UCLA Health accepts most PPO insurance policies and select HMO policies with authorization from the patient's primary care provider. Insurance providers that typically cover weight loss procedures accepted by UCLA Health include Aetna, Anthem Blue Cross Blue Shield, Cigna, Oscar, Tricare, and United Health Care. UCLA Health also has a designated relationship with Blue Cross Blue Shield's Bariatric Resource Service (BRS).
Cura Insurance:
Cura Insurance offers specialist life insurance policies for individuals who have undergone or are planning to undergo gastric bypass surgery. These policies may come with exclusions or increased premiums due to the perceived risks associated with surgery. Cura Insurance also provides income protection policies, which may be available at non-standard terms, depending on the individual's recovery and current health status.
Other Insurance Companies:
Other insurance companies that have been mentioned as covering bariatric surgery include BUPA UK and Global, AXA PPP Healthcare, Aviva, WPA, Vitality, Health-on-line, The Exeter, and Norwich Union.
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Pre-authorisation requirements
Bariatric surgery is a significant procedure that can transform lives, and many insurance companies recognise the serious health threats posed by obesity and cover weight-loss surgery. However, insurance companies have pre-authorisation requirements that must be met before the procedure is approved. These requirements vary based on the insurance company and the policies in place. Here are some general pre-authorisation requirements that are expected:
- Initial Assessment: The first step is an initial assessment by the primary care provider to determine if the patient meets the minimum criteria for bariatric surgery. This assessment addresses the treatment of obesity-related medical conditions.
- Pre-operative Medical Clearance: Before approval, a comprehensive medical evaluation is required to ensure the patient is a suitable candidate for surgery. This includes assessing the presence of any co-morbid conditions, such as pseudo tumor cerebri, where the benefits of surgery must outweigh the risks.
- Pre-operative Nutritional Counselling: As bariatric surgery often results in significant dietary changes post-operation, pre-operative nutritional counselling with a registered dietitian is necessary. The dietitian will assess and certify the patient's ability to comply with these lifelong dietary changes.
- Pre-operative Education: Patients must undergo education to understand the risks and benefits of the surgery and develop realistic expectations. This education also emphasises the need for long-term follow-up care and adherence to behavioural modifications.
- Psychological Evaluation: A pre-surgical psychological evaluation is standard for bariatric surgery. This evaluation addresses the presence of substance abuse, drug use habits, and any psychiatric illnesses that may impact the patient's suitability for surgery.
- Weight Loss: Some insurance providers may require patients to lose a certain percentage of their body weight and maintain that weight loss until the time of surgery. This demonstrates a commitment to a healthier lifestyle and improves surgical outcomes.
- Diabetic Control: For diabetic patients, documentation of efforts in diabetic control or stabilisation is essential. This may include specific requirements, such as maintaining blood sugar levels within a certain range.
- X-ray Images: Current plain film X-ray images may be requested to assess the patient's physical health and suitability for surgery.
- Specific Exclusions: Insurance providers may have specific exclusions for bariatric surgery approval. For example, patients with diagnoses of multiple sclerosis, pregnancy, refractory depression, or active substance abuse may not be eligible for coverage.
It is important to note that these requirements are not exhaustive, and specific insurance providers may have additional or modified pre-authorisation criteria. Always consult with your insurance company and healthcare provider to understand their specific pre-authorisation requirements for bariatric surgery.
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Insurance coverage options
Understanding Coverage Options:
Firstly, it's important to note that insurance coverage for bariatric surgery is not a given and may depend on the specific requirements and exclusions of your insurance plan. Some insurance providers recognize the serious health threats associated with obesity and do cover weight loss surgery, but often strict qualification requirements must be met. These requirements may include having a certain body mass index (BMI), a history of obesity-related health conditions, and documentation of previous attempts to lose weight through dieting or other methods.
Insurance Providers and Plans:
Some insurance providers that typically cover weight loss procedures include Aetna, Anthem Blue Cross Blue Shield, Cigna, Oscar, Tricare, and United Health Care. Additionally, Medicare covers certain bariatric surgical procedures, such as gastric bypass surgery and laparoscopic banding surgery, when specific conditions related to morbid obesity are met. It is always advisable to contact your insurance company directly to understand the specifics of your plan and any pre-authorization requirements.
Pre-Authorization:
To obtain pre-authorization from your insurance company, your surgeon will usually prepare a letter to establish the "medical necessity" of the surgery. This letter should include detailed information such as your height, weight, BMI, obesity-related health conditions, and the impact of your weight on your daily activities. It is beneficial to include supporting information from medical journals highlighting the effectiveness of weight loss surgery in treating obesity-related conditions.
State-Specific Mandates:
It is worth noting that certain states have specific mandates regarding insurance coverage for bariatric surgery. For example, Mississippi law requires state employee health plans to cover obesity treatment, including bariatric surgery, for a limited number of employees annually. New Hampshire mandates that health insurers offer bariatric surgery as a treatment option for obesity-related diseases. Georgia, Indiana, Maryland, and Virginia recommend or mandate that insurers offer coverage for additional premiums. Therefore, it is essential to be aware of the specific regulations in your state.
Appeals Process:
If your initial request for pre-authorization is denied, don't lose hope. Insurance providers typically have an appeals process that allows you to address the specific reasons for the denial. It is recommended to act quickly and enlist the help of an experienced insurance attorney or advocate to navigate the complexities of the appeals process effectively.
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Insurance appeal process
Bariatric surgery is covered by some insurance companies, but it is important to check with your provider. Medicare, for example, covers some bariatric surgical procedures, but only when certain conditions related to morbid obesity are met.
If your insurance company denies your initial request for coverage, you can appeal the decision. It is important to act quickly as some insurers place limits on the number of appeals and there may be a specific deadline by which you must appeal. The first step is to understand why your request was denied. Reasons can range from not meeting a specified criterion, such as a level of obesity, to not passing psychological exams. Once you understand the reason for the denial, you can write and submit a letter of appeal to the insurance company. This letter should be factual and persuasive, yet pleasant and polite, and should include the following:
- Patient identification information, such as your name and policy number
- The reason for the denial
- A brief health history, including previous weight loss attempts and why bariatric surgery is necessary
- Information to correct any errors, such as a wrong procedure coding error
You may also want to call your company's Human Resources Department to explain the situation. They may be able to tell you if the surgery should be covered and may even call the insurance carrier on your behalf. It is also a good idea to have the support of your primary care physician before visiting a bariatric surgeon.
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Insurance coverage for state employees
Insurance coverage for bariatric surgery varies depending on location and insurance provider. In the United States, Medicare covers some bariatric surgical procedures, such as gastric bypass surgery and laparoscopic banding surgery, when certain conditions related to morbid obesity are met. However, it is important to note that Medicare does not cover transportation costs to and from the bariatric surgery center. The cost of surgery can vary depending on the services required, and it is recommended to consult directly with the doctor, hospital, or facility to understand the financial implications.
Some states have specific legislation regarding insurance coverage for bariatric surgery for state employees. For example, Mississippi law requires state employee health plans to provide coverage for obesity treatment, including bariatric surgery, for up to 100 employees annually. Similarly, Arkansas' Act 855 mandates insurance coverage for surgeries to treat morbid obesity for state employers and public school teachers, including gastric bypass and gastric banding surgery. In addition, Oregon and Indiana courts have ruled that state worker's compensation insurance must cover bariatric surgery for employees injured at work when weight loss is necessary for successful treatment.
It is important to note that insurance companies may have specific requirements or exclusions for weight loss treatments, including surgery. Some insurers may require individuals to meet certain conditions or demonstrate that other weight loss methods have been unsuccessful before approving coverage. It is recommended to contact your insurance provider directly to understand your specific coverage and any requirements or exclusions that may apply.
To initiate the process of seeking insurance coverage for bariatric surgery, it is advisable to first contact your insurance company to discuss flexible surgery and medical benefits. Once authorization is obtained, individuals are typically required to attend a mandatory pre-operative nutrition class and a psychiatric evaluation to ensure their health and safety, as weight loss surgery is a significant life-altering procedure.
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Frequently asked questions
Yes, you can get medical insurance after bariatric surgery, but it is important to note that not all insurance plans will cover weight loss treatments and each plan has different requirements. It is best to contact your insurance company directly to understand your coverage.
It is recommended to read and understand the "certificate of coverage" provided by your insurance company. You may need to start with your primary care physician and get a referral to a qualified bariatric surgeon. Before visiting the surgeon, organize your medical records, including your history of dieting efforts and obesity-related issues.
The pre-authorization letter will include your height, weight, Body Mass Index (BMI), and any documentation about how long you have been overweight. It will also include a description of obesity-related health conditions, a history of medications, and how these conditions have impacted your everyday life.
Insurance companies like Aetna, Anthem Blue Cross Blue Shield, Cigna, Oscar, Tricare, and United Health Care typically cover weight loss procedures. Medicare also covers some bariatric surgical procedures, like gastric bypass surgery and laparoscopic banding surgery, when certain conditions related to morbid obesity are met.
