How to Get Insurance to Pay for Bariatric Surgery

Streamline your insurance verification process.

You can simplify the process of getting insurance to pay for bariatric surgery by learning how. Insurance coverage is an important consideration for the majority of patients, with an average cost ranging from $18,000 to $36,000. Forecasts predict that the bariatric surgery market will experience an annual compound growth rate (CAGR) of 9.56% from 2019 to 2028. Bariatric surgery can offer a way to improve the quality of life and health for an increasing number of weight-loss patients.

Read on to know which states require insurance plans to cover bariatric surgery and the typical insurance criteria for bariatric surgery coverage.

Key Takeaways.

  • Most insurance policies include coverage for bariatric surgery. Coverage for bariatric surgery is mandatory in 23 states for all individual, family, and small group insurance policies.
  • The majority of insurers require a BMI of at least 40 (or 35 with co-morbidities) to qualify patients for bariatric surgery coverage.
  • Other typical criteria for evaluation of psychological evidence include substance abuse and cessation of smoking, as well as past attempts at weight loss including the demonstration of medical necessity for bariatric surgery.
  • Bariatric surgery can often be an expensive procedure, costing tens of thousands of dollars, which many insurance plans in the U.S. May cover when certain criteria are met by the patient.

    According to a recent study on the requirements for bariatric surgery, it was found that 95% of companies have a well-defined policy for pre-approval. All companies included coverage for Roux-en-Y bypass surgery, while the majority also provided coverage for laparoscopic adjustable gastric banding or sleeve gastrectomy.

    The majority of insurers require a BMI of 35 or above, with a co-morbidity present, and prior approval for bariatric surgery. This approval is obtained through a medically supervised weight management program (MWM) with a BMI of 40 or above.

    States Where Insurance is Required to Cover Bariatric Surgery

    States are those that require 23 small group insurance plans for bariatric surgery coverage, as well as individual and family insurance plans.

  • Arizona.
  • California.
  • Colorado.
  • Delaware.
  • Hawaii.
  • Illinois.
  • Iowa.
  • Maine.
  • Maryland.
  • Massachusetts.
  • Michigan.
  • Nevada.
  • New Hampshire.
  • New Jersey.
  • New Mexico.
  • New York.
  • North Carolina.
  • North Dakota.
  • Rhode Island.
  • South Dakota.
  • Vermont.
  • West Virginia.
  • Wyoming.
  • Additionally, under the ACA, bariatric surgery coverage must be provided in at least three states, with some exceptions.

  • Georgia, where a 1999 state law also requires coverage for severe obesity.
  • Indiana, where a 2000 state law also requires coverage for severe obesity.
  • As per a state law passed in Virginia in 2000, every health insurer regulated by the state must provide coverage for severe obesity in at least one plan.
  • A map showing the states requiring bariatric surgery insurance
    Source: https://www.bariatric-surgery-source.com/bariatric-surgery-insurance.html

    Medicare and Medicaid Coverage of Bariatric Surgery

    Both Medicare and Medicaid cover some bariatric procedures, including gastric bypass surgery and laparoscopic banding surgery, for patients who meet the criteria.

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

    The criteria for bariatric surgery typically vary but include the following exact ones. In addition, this means that you’ll need to provide evidence that the surgery is necessary for each patient. Most insurance plans require medical necessity to be demonstrated before granting coverage for weight-loss surgery.

    Age 18 or Older

    The majority of plans do not provide coverage for pediatric weight loss surgery. Typically, only individuals who are 18 years of age or older can undergo bariatric surgery.

    Body Mass Index Above 40

    Individuals seeking bariatric surgery must have a body mass index (BMI) of 40 or above, as required by most insurance providers.

    Alternatively, patients with moderate obesity may be candidates for bariatric surgery if they have at least 35 BMI, and co-morbidities such as high blood pressure, type 2 diabetes, significant clinically obstructive sleep apnea, and coronary heart disease.

    A diagram showing the range from normal weight to morbid obesity
    Source: https://www.firsthealth.org/lifestyle/news-events/2019/6/a-way-to-rewind-the-clock-and-start-fresh

    Approved is surgery before time of duration particular a for obese or morbidly be to patient your require may companies insurance some.

    Past Attempted Weight Loss

    Most insurance companies require that patients have made sufficient efforts to lose weight before approving coverage for bariatric surgery. These efforts can include completing a medically supervised weight loss plan developed by a doctor or recommended by an insurance provider, as well as making other efforts to lose weight.

    To obtain insurance approval, it is probable that you will need to present evidence of the efforts made to shed pounds, such as records of dietary and physical activity routines. If your patient has not achieved successful weight loss during this timeframe, they might be deemed eligible for bariatric surgery.

    Psychological Evaluation

    Most insurance companies will require your patient to undergo a psychological evaluation before they approve the bariatric surgery, as well as provide long-term support and information for the success of the surgery.

    The psychological assessment will examine their:

  • Motivations for pursuing bariatric surgery.
  • Weight and dietary background.
  • Present dietary habits.
  • Comprehension of the surgical procedure and the lifestyle modifications that come with it.
  • Social assistance and past events.
  • Psychiatric history.
  • In the video below, Dr. James Glynn discusses further about what patients can anticipate from their psychological assessment.

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    Quit Smoking and Avoid Substance Abuse

    Finally, most insurance companies will require that your patient ceases smoking and does not display any evidence of substance abuse (within the past 5 years) or recent history of substance abuse before covering bariatric surgery.

    Use Modern Tools to Help with Insurance Approvals and Billing

    It is crucial for each insurance company to consistently apply the latest criteria to ensure that your patients are able to undergo approved surgeries. By using the latest tools, you can further simplify the insurance process for you and your patients, helping to streamline the pre-authorization process and tailor the evaluation requirements accordingly.

    Discover how Wellbe’s personalized care automation can streamline insurance approvals and hundreds of other non-medical administrative tasks, including billing.