INSURANCE

Does My Insurance Cover the Surgery?

Many health insurance plans, including Medicare and most Medicaid plans, cover bariatric surgery. However, health insurance coverage varies, so it’s important to examine the coverage provided by your specific plan. We can’t tell you whether your insurance plan covers surgery, however on this page we will explain how to work with your insurance provider to see if you have bariatric surgery insurance coverage.

Step 1: Find out if you have insurance coverage for bariatric surgery by calling your insurance company. Insurance language can be confusing.

In addition to reading through your benefits brochure, we recommend asking the following questions when you call:

  • Is bariatric surgery a covered benefit under my plan? If so, which procedures? You will need to provide your I.D. number and Group Number, which are found on your insurance card, so keep this information handy.
  • 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? What is the annual deductible 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 and 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 July 30th you will only be responsible for the remaining $125 of your deductible. However, if you have surgery on August 2, you would be responsible for the full $1,000 deductible.
  • 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 bariatric surgery is covered under your policy, you will work with us to gather all the required documentation for pre-approval, which is almost always required for weight loss surgery. It is a way to make sure the procedure is covered under your policy. Typically, our office will submit the required information to your insurance provider.

Some of the most common bariatric insurance coverage requirements include:

  • Body mass index (BMI) greater than 40 or BMI greater than 35 with co-morbidities (diabetes, high blood pressure, etc.).
  • 18 years of age or older.
  • Diagnosis of morbid 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.
  • Documentation of failed diet and exercise plans.

Step 3: Follow up to make sure your insurance company has received your materials.

Check in with our office to ensure that all required materials have been submitted on your behalf, 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 appeals process.
  • Contact your provider to confirm that they have received your appeal.
  • Notify the 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 financing options. You may find that bariatric surgery is more affordable than you think.
    • You may want to speak with your employer about getting an individual approval for surgery.
    • 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 influence the insurance company’s policies.

    Learn More with Related Pages:
    Getting Started with Bariatric Surgery
    Bariatric Surgery FAQs
    Am I a Candidate?
    Information Seminar
    Financing Bariatric Surgery