Will Insurance Pay For Weight Loss Surgery? A Complete Guide

An increasing number of individuals find weight-loss surgery beneficial for their health and well-being.

Projections suggest a 9.56% compound annual growth rate (CAGR) for the bariatric surgery market from 2019 to 2028.

Given the average cost ranging from $15,000 to $36,000, insurance coverage becomes a crucial factor for most patients.

Discover ways to streamline the insurance process for surgical patients seeking coverage for bariatric surgery.

Explore mandatory coverage in certain states and typical insurance criteria for this procedure.


will insurance pay for weight loss surgery
Weight loss surgery can often be covered by insurance, but it’s essential to understand your policy’s specifics. Learn about the criteria, exclusions, and states mandating coverage for weight loss surgery to maximize your insurance benefits./PHOTO COURTESY

Does Insurance Cover Bariatric Surgery?

Bariatric surgery often incurs substantial costs, reaching tens of thousands of dollars.

In the United States, many insurance plans offer coverage for this procedure, provided patients meet specific criteria.

A recent survey on bariatric surgery coverage criteria found that 95% of surveyed companies have clearly outlined pre-authorization policies.

Most insurance plans covered Roux-en-Y bypass surgery, with many also including laparoscopic adjustable gastric banding or sleeve gastrectomy.

Generally, insurers require individuals to have a Body Mass Index (BMI) of 40 or higher, or a BMI of 35 or higher with an associated co-morbidity.

Additionally, a supervised medical weight management program (MWM) was often a prerequisite for bariatric surgery approval by insurers.

States Where Insurance is Required to Cover Bariatric Surgery

Under the Affordable Care Act’s (ACA) Essential Health Benefits (EHB) Benchmark Plans, 23 states mandate coverage for bariatric surgery within individual, family, and small group insurance plans. These states include:

1. Arizona
2. California
3. Colorado
4. Delaware
5. Hawaii
6. Illinois
7. Iowa
8. Maine
9. Maryland
10. Massachusetts
11. Michigan
12. Nevada
13. New Hampshire
14. New Jersey
15. New Mexico
16. New York
17. North Carolina
18. North Dakota
19. Rhode Island
20. South Dakota
21. Vermont
22. West Virginia
23. Wyoming

Moreover, in three additional states, coverage for bariatric surgery must be provided in at least some policies:

1. Georgia, where a 1999 state law mandates coverage for morbid obesity
2. Indiana, where a 2000 state law mandates coverage for morbid obesity
3. Virginia, where a 2000 state law requires that coverage for morbid obesity be offered in at least one plan by each state-regulated health insurer

How to Get Insurance to Pay for Bariatric Surgery by Demonstrating Medical Necessity

Insurance plans often demand proof of medical necessity before approving coverage for weight-loss surgery.

This typically involves meeting specific criteria that vary among providers but commonly include the following:

1. Age Requirement
Patients seeking bariatric surgery must typically be 18 years or older. Pediatric bariatric surgery is usually not covered by most plans.

2. Body Mass Index (BMI)
Insurance providers commonly require a BMI of 40 or higher for bariatric surgery candidacy.

In some cases, patients with a BMI of at least 35 may qualify if they have accompanying health issues such as high blood pressure, type 2 diabetes, clinically significant obstructive sleep apnea, coronary heart disease, or hypertension.

Use Modern Tools to Help with Insurance Approvals and Billing

Staying informed about and consistently adhering to the most recent criteria established by each insurance company is crucial to securing approval for your patients’ surgeries.

Employing up-to-date tools can significantly simplify the insurance procedure, allowing for tailored evaluations and streamlining the pre-authorization process for both you and your patients.

Is there any waiting period in health insurance for weight loss surgery?

Several insurance companies impose a waiting period, starting from the initial approval to the actual surgery.

This waiting period, typical in health insurance, also applies to patients preparing for weight loss surgery and may span between 2 to 4 years.

Simplifying matters, reimbursement for weight loss surgery expenses is usually permissible only after fulfilling the waiting period after policy purchase.

It’s advisable to consider including this benefit in your initial insurance policy.

Exclusions under health insurance for weight loss surgery

Insurance policies often contain specific exclusions that should be thoroughly understood before initiating a claim, especially in the context of surgical procedures.

Before undergoing weight loss surgery, it’s crucial to discuss the precise inclusions and exclusions with your insurance provider.

Here are common exclusions associated with weight loss surgery under health insurance:

1. Claims during the initial waiting period of the plan, usually around 30 days, are not typically covered.

2. Similar to cosmetic procedures, weight loss surgery isn’t covered if pursued for aesthetic reasons.

3. Pre-existing condition-related claims are generally excluded from health insurance plans.

4. Instances where weight gain stems from factors like medication effects, mental health issues, poor eating habits, or quality of life aren’t typically covered.

5. Basic medical insurance plans usually don’t include financial coverage for weight loss surgery. However, some insurers offer it as an additional cover for an added premium.

It’s prudent to engage in detailed discussions with your insurance provider to understand the specifics of your policy.

While the inclusion of weight loss surgery in insurance plans is becoming more common and customer-friendly, conducting comprehensive research before purchasing any health insurance plan online is essential.

What to Claim for Bariatric Surgery?

To process a claim for bariatric surgery within your health insurance policy, meeting specific conditions and submitting essential documents is crucial:

1. Surgeon’s prescription for diagnostic tests and authorization for the surgery.

2. Submission of medical reports and detailed descriptions related to the bariatric surgery expenses.

3. Requirement: Patient BMI of 40 or higher.

4. Alternatively, a BMI of 35 or above along with health complications such as sleep apnea, Type 2 Diabetes, and cardiovascular issues.




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