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Insurance

Will Insurance Cover My Weight Loss Surgery?

Depending on the type of major medical insurance policy you have, most insurance companies will pay for bariatric surgery if you meet certain conditions. However, some insurance companies refuse to cover any treatment related to “losing weight,” although they will treat the diseases caused by excessive body weight.

We have assembled a list of insurance companies and their criteria for determining weight loss surgery coverage.

For those patients on Medicare, the US Government now covers three types of surgical weight loss procedures:

For questions about qualifying, please see our insurance page.

How do I qualify for coverage?

Your bariatric surgery must be considered a medical necessity in order to be covered by insurance. Every insurance company has their own requirements and yours will make their final decision based on if you meet those requirements. Many insurance companies rely on the information your doctor sends to them, but others may require you to be seen by their own doctor before a decision is made.

To qualify for coverage, certain conditions must exist and your weight problem must put your life at serious risk.

Some of the requirements may include:

  • Current height, weight, and body mass index (BMI)
  • A psychological evaluation
  • Certain medical tests
  • Current medications
  • A complete medical history, including documentation of morbid obesity
  • Detailed dieting efforts history, including exercise programs, gym memberships
  • Description of all obesity-related health conditions that are or may be caused by your morbid obesity, including but not limited to, high blood pressure, diabetes, heart and blood vessel disease, sleep apnea, gastroesophageal reflux, arthritis and high cholesterol
  • A recent medically-supervised diet history, many insurance companies require six months’ of a supervised diet program
  • A description of how the obesity affects your daily activities

While genetics and metabolic rate do affect how much a person weighs, the primary causes of obesity are often emotional and psychological. Surgery will not fix these emotional and psychological problems.

How much of my weight loss surgery will my insurance carrier cover?

There are a variety of different expenses associated with gastric bypass surgery:

  • Testing to determine eligibility for gastric bypass surgery
  • Pre-admission testing
  • In-hospital costs
  • Surgeon and other doctor fees
  • Post-surgery medication and care

If you are approved for bariatric surgery, your insurance company will pay between 50 to 100 percent of the hospital and doctor fees. Some policies may even cover in-home nursing care after release from the hospital if the doctor determines it is necessary.

Even if your insurance company will not cover the cost of the actual procedure, they may cover one or more of the other costs related to your gastric bypass surgery.

If I lack insurance coverage, can I still consider weight loss surgery?

Once we meet with you, our Surgical Coordinator will help you determine what will and will not be covered by your specific policy.

Since 2000, the total cost of all medically necessary weight loss treatments has been considered a deductible medical expense for income tax purposes. Those tax deductions for weight loss surgery can help you pay for at least part of the cost of your bariatric surgery or help you get reimbursed for your surgery co-payment.

It is useful to know that under the Internal Revenue tax code, treatment for weight loss includes behavioral counseling, nutritional counseling, prescriptions, and gastric bypass surgery if those treatments are prescribed to treat or prevent specific diseases caused by excessive body weight.

Insurance Companies and Bariatric Surgery Coverage

Following are guidelines supplied by some insurance companies on the criteria used to determine weight loss surgery eligibility:

ANTHEM BLUE CROSS BLUE SHIELD

  • BMI exceeding 40
  • BMI of 35 and 39.9 with one comorbidities
  • Nutritional Evaluation
  • Psychiatric Evaluation

BLUE CROSS BLUE SHIELD FEDERAL

  • BMI exceeding 40 for at least 24 months
  • BMI of 35 and 39.9 with two comorbidities for at least 24 months
  • 3 months MSWLT to include Nutritional Evaluation
  • Psychiatric Evaluation

BLUE CROSS BLUE SHIELD ILLINOIS

  • BMI exceeding 40
  • BMI of 35 and 39.9 with two comorbidities
  • 6 months MSWLT
  • Psychiatric Evaluation

BLUE CROSS BLUE SHIELD TEXAS

  • BMI exceeding 40
  • BMI of 35 and 39.9 with two comorbidities
  • 6 months MSWLT
  • Psychiatric Evaluation

CIGNA

  • BMI exceeding 40 (for the last 24 months)
  • BMI of 35 and 39.9 with one comorbidities (for the last 24 months)
  • 6 months MSWLT
  • Nutritional Evaluation
  • Psychiatric Evaluation

EMPIRE BLUE CROSS BLUE SHIELD

  • BMI exceeding 40
  • BMI of 35 and 39.9 with one comorbidities
  • Nutritional Evaluation
  • Psychiatric Evaluation

HIGHMARK BLUE CROSS BLUE SHIELD

  • BMI exceeding 40
  • BMI OF 35 AND 39.9 with two comorbidities
  • Nutritional Evaluation (isn’t included in the 6 months MSWLT)
  • 6 months MSWLT
  • Psychiatric Evaluation

MEDICAID

  •  BMI exceeding 35
  •  Has at least one major, or with two comorbidities
  • 12 months MSWLT
  • Psychiatric Evaluation

MEDICARE

  • BMI exceeding 35
  • At least one comorbidities
    • Obstructive Sleep Apnea
    • Type 2 Diabetes
    • Benign Essential Hypertension
  • Required to lose 20 pounds
  • 3 months MSWLT (To Include Nutritional Evaluation)
  • Psychiatric Evaluation

TRICARE

  • 100 pounds of ideal weight with at least one comorbidities related to obesity
  • Patient is 200 percent or more over the ideal body weight and body structure

UNITED HEALTH CARE

  • BMI exceeding 40
  • BMI of 35 and 39 with two comorbidities
  • 6 months MSWLT
  • Nutritional Evaluation
  • Psychiatric Evaluation

UNITED MEDICAL RESOURCES

  • BMI exceeding 40
  • BMI of 35 and 39.9 with two comorbidities
  • 6 months MSWLT
  • Psychiatric Evaluation
  • Following the surgery, patient must continue active participation in the URPG Comprehensive Weight Management Center Program for 24 months. Failure to comply with these guidelines will result in a $2,000 repayment penalty.