Insurance Coverage For Your Bariatric Surgery: Getting Your Approval!

Getting bariatric surgery can be life-changing—leading to incredible health transformations that resolve obesity-related diseases like diabetes and high blood pressure. However, the high out-of-pocket surgery costs mean that insurance approval is vital. This article shares insider tips for dealing with insurance carriers and getting your bariatric procedure approved and paid for.

Insurance Coverage Basics

Many health insurance plans cover bariatric surgery, but coverage can vary greatly. Here are some key factors to understand:

• Prior authorization - Most plans require you to get approval in advance before they will cover bariatric surgery. This involves showing that the surgery is medically necessary.

• Requirements - Insurance plans may require that you:

  • Have a BMI over 40, or over 35 with an obesity-related condition like diabetes or sleep apnea

  • Show proof you've tried to lose weight through other means for 6-12 months without success

  • Use an in-network bariatric surgeon and facility

• Self-funded plans - If you have a self-funded plan through an employer, coverage may differ. These are not regulated by state laws.

• Medicaid - Some state Medicaid programs cover bariatric surgery but have extensive prerequisites or only approve procedures on a case-by-case basis.

• Medicare - Medicare provides national coverage for bariatric surgery for eligible beneficiaries. Requires medically supervised weight loss efforts for 6 months.

Getting denied for authorization can happen for various reasons, such as not meeting the BMI criteria or not adequately documenting failed weight loss attempts through other methods. Having your surgeon provide thorough medical justification improves your chances of getting approved.

The prior authorization process can take some time, so be sure to start the process 1-2 months before your target surgery date. You can appeal denials through your insurance company's internal appeals process.

Questions to Ask Your Insurance Provider

When looking into bariatric surgery, be sure to check the following details thoroughly with your insurance provider:

• Is prior authorization required? How far in advance does it need to be submitted - 30 days, 60 days, 90 days before surgery? Getting this process started early is important.
• Which specific bariatric procedures are covered? For example, does coverage include gastric bypass, gastric sleeve, and gastric band? Are any procedures excluded?
• Is surgery coverage limited to certain facilities or designated bariatric centers of excellence? Many insurers restrict coverage to hospitals and surgery centers they have contracted with.
• Does the insurer require using an in-network surgeon? Search their provider directory for in-network bariatric surgeons.
• What are the out-of-pocket costs? What is your deductible and has it been met? What is the coinsurance percentage you will owe? Get specifics on copay amounts for the surgeon, facility, anesthesiologist, etc.
• What pre-surgery requirements may have cost sharing? For example, visits to a nutritionist, sleep study, psychological evaluation.
• What post-surgery services are covered? For instance, nutritional supplements, follow-up visits with your bariatric surgeon, care from a dietician.

Having all of this information from your insurer ahead of time allows you to budget accurately and avoid surprise expenses. Be your own best advocate and don't hesitate to ask lots of questions to understand exactly what your policy covers when it comes to bariatric surgery and related healthcare services.

Additional Costs to Factor In

Some related expenses to budget for:

• Pre-surgery - Required visits to a dietitian, psychologist, sleep study, etc. These evaluations might require cost sharing, implying that you, as a patient, might be responsible for a portion of these costs, depending on your insurance policy.

• Post-surgery - Nutritional bariatric supplements, necessary due to altered nutrient absorption after surgery, can cost between $100 to $300 monthly. This expense often comes out-of-pocket, as most insurance plans don't cover dietary supplements.

• Plastic surgery - After significant weight loss, patients may choose to undergo plastic surgery procedures, such as abdominoplasty or body contouring, to deal with excess, loose skin. These procedures can be quite expensive, potentially exceeding $25,000, and are often not covered by insurance, unless it's proven medically necessary.

Appealing Insurance Denials

If your bariatric surgery claim is denied, you can file an appeal with your insurance provider:

• Get your bariatric surgeon's help providing medical documentation explaining why surgery is medically necessary for you. This can detail your health history, prior weight loss attempts, and why the surgery is medically necessary, thus strengthening your claim.

• Highlight relevant clinical guidelines and coverage policies by authoritative bodies that support approving surgery for your situation. For instance, guidelines by the American Society for Metabolic and Bariatric Surgery or the National Institute of Health can serve as powerful tools in your appeal process, showing that your case aligns with recognized medical standards.

• Before seeking external review, ensure you've followed your insurance provider's internal appeal processes. This typically includes submitting written appeals and possibly additional documentation or discussions with a company representative.

Be Tenacious in Appealing Insurance Denials

Even if you follow all the pre-authorization guidelines, approval is not guaranteed. Denials often occur because certain medical necessity criteria is lacking. But with a strategic appeal process, you can potentially get these adverse decisions overturned. Here are some tips:

• Get a copy of the denial letter detailing the exact reasons for rejection.

• Ask your bariatric surgery team to draft professional appeal letters highlighting why the procedure is medically vital given your health risks. Provide additional documentation like:

• Records showing failed weight loss attempts

• Testing confirming diagnosis of comorbid conditions

• Letters emphasizing severity of obesity complications

• Persist through second and third appeals if needed—they often get approved! Reach out to state insurance regulators to put added pressure.

Take Steps to Strengthen Your Case

You can also take proactive measures to address potential insurance objections and demonstrate medical necessity:

• Work with a nutritionist to document failed dieting attempts.
• Get testing done to definitively diagnose comorbidities like sleep apnea.
• Enroll in a comprehensive 6-12 month weight management program under physician supervision.
• Complete all pre-surgery requirements like nutrition classes, psychological counseling, endoscopies etc.

Having your bariatric surgeon provide a strongly-worded recommendation letter outlining the risks of not getting surgery can also sway approval decisions in your favor.

Self-Pay May Be an Option if Insurance Fails

If you exhaust all avenues of appeal without success in getting insurance to cover costs, self-pay options for bariatric surgery do exist. Just be cautious of predatory lending practices. Consider:

• Reputable financing companies that offer loans tailored to bariatric patients at reasonable rates
• Negotiating prompt-pay cash discounts with hospitals/surgeons
• Finding more affordable options at accredited bariatric centers abroad

While self-pay is challenging, it can widen access for those without coverage. Weigh the pros and cons carefully given the financial risks.

Getting insurance to cover weight loss surgery requires grit and perseverance. But the long-term health payoffs make it worth fighting for. With the right game plan and support team, you can overcome coverage obstacles in your path.

Frequently Asked Questions

What are the typical insurance requirements for covering bariatric surgery?

Most insurance plans require you to have a BMI over 40, or over 35 if you have an obesity-related condition. You also typically need documentation of failed weight loss efforts for 6-12 months using other methods like diet and exercise programs.

Do I have to use certain bariatric surgeons or facilities?

Many insurers limit coverage to their in-network surgeons and accredited bariatric facilities. Check your plan details to ensure your provider choices will be covered.

What if my claim for bariatric surgery is denied?

You can appeal the denial and provide additional medical documentation from your surgeon explaining why the bariatric procedure is medically necessary for your situation.

Author: Carrie H. Carrie is a passionate health and nutrition writer who transforms complex medical research into accessible, evidence-based content to empower readers to make informed choices about their wellbeing. With a background in science and a dedication to helping others live healthier lives, she provides thoughtful analysis of the latest studies and practical, actionable advice readers can apply to their own lives.

Reviewed By: Dr. Huffman Dr. Huffman is an accomplished board-certified bariatric physician with extensive clinical experience and expertise in treating obesity. He has trained countless healthcare providers and founded American Bariatric Consultants to develop highly sought-after protocols, training materials and continuing education used widely by medical societies, hospitals and physicians. Dr. Huffman's impact reaches far beyond direct patient care, as he actively prepares the next generation of physicians to achieve board certification in bariatrics, thereby exponentially expanding access to this vital medical treatment.