We can’t tell you whether your insurance covers surgery, but on this page we will explain how to work with your insurance provider to see if you have bariatric surgery insurance coverage.
Many health insurance plans, including Medicare and most Medicaid plans, cover bariatric surgery. However, health insurance plan coverage varies, so it’s important to examine the coverage provided by your plan.
Step 1: Find out if you have coverage for bariatric surgery.
Insurance language can be confusing. In addition to reading through your benefits brochure, we recommend calling your insurance provider and asking the following questions:
Is bariatric surgery a covered benefit under my plan?
You will need to provide your I.D. number and Group Number, which are found on your insurance card, so keep this information handy.
What bariatric surgery procedures are covered?
Many insurance companies pay for these weight loss procedures, but you should ask to be sure.
May I have a copy of the Medical Policy statement for bariatric surgery insurance coverage?
You have the right to access this information under most insurance agreements.
What is the co-pay amount, if any?
What is the annual deductible, if any and how much have I met so far?
When does my annual deductible renew?
Knowing when your deductible renews can help you reduce your out-of-pocket costs. Here's how: Let's say you have already met $875 of your $1,000 annual deductible, and your insurance plan year begins (renews) on August 1. If you have surgery on August 2, you would again be responsible for the $1,000 deductible amount, instead of the remaining $125 from the previous year.
Are there any hospitals or surgeons in the area that you do not contract with?
Knowing the answer can help you select a surgeon who is included in your plan, and help you reduce your out-of-pocket costs.
Step 2: If surgery is covered, work with your bariatric practice to gather all the required documentation for pre-approval.
Pre-approval is almost always required for weight loss surgery. It is a way to make sure the procedure is covered under your policy. Typically, your surgeon's office will submit the required information to your insurance provider to gain pre-approval.
Some of the most common bariatric insurance coverage requirements include:
- Body mass index (BMI) greater than 40 or BMI greater than 35 with comorbidities (diabetes, high blood pressure, etc.).
- 18 years of age or older.
- Diagnosis of severe obesity.
- Participation in a physician-supervised weight loss program for extended time periods (this can vary from 3 to 12 consecutive months, depending on your insurance plan).
- Psychological evaluation prior to surgery. Your bariatric clinic will either provide this service or refer you to a psychologist.
- Documentation of failed diet and exercise plans.
Step 3: Follow up to make sure your insurance company received your materials
Check in with your bariatric practice to ensure that they submitted your information, or follow up with your insurance company in about a week if you submitted materials yourself. In either case, it doesn't hurt to contact your insurance directly. You'll find that patience and persistence can help as you go through this process.
Step 3a: If you are approved, congratulations!
Step 3b: If you are denied coverage, don't be discouraged, and don't be afraid to contact your provider and ask questions.
- Determine why bariatric surgery is not covered. Ask your insurance provider for specific reasons.
- Insist on a written denial.
- Request that your provider reconsider your request. Call the member services phone number listed on your insurance card. You will also need to know your group number, which is also on the insurance card. Request the necessary steps required to file an appeal.
- File your appeal. You may want to consider working with your bariatric practice to discuss the next steps in appealing for coverage. They can help you navigate the appeal process.
- Contact your provider to confirm that they have received your appeal.
- Notify your surgeon's office after your appeal has been submitted so they can record it in your chart.
- Follow up with your insurance provider several weeks after filing your appeal.
What to do if your appeal is denied
If you are denied coverage after you appeal, consider alternative options. You may find that bariatric surgery is more affordable than you think.
Call your state insurance department to register a complaint. Find the number for your state below. Although they may not be able to help with your particular situation, your complaint—along with countless others—may collectively help to change the reimbursement policy.
As you can see, this process is complicated. A great way to learn more about the bariatric insurance approval process is to attend an information seminar hosted by a trained surgeon at a bariatric surgery clinic that offers gastric banding, gastric bypass, or sleeve gastrectomy. There’s no pressure to make a commitment – and no better way to get the answers you’re looking for.
State insurance departments and phone numbers
Lastly, you can try calling your state insurance department to register a complaint. Many states are required to have an independent, external board evaluate the validity of denied coverage. And, although they may not be able to help with your particular situation, your complaint — along with countless others — may collectively help to change the reimbursement policy.