The journey to a healthier weight can be complex, and understanding insurance coverage for weight loss clinics, medications, and procedures is a crucial part of the process. This article aims to provide a comprehensive overview of what to expect when seeking insurance coverage for weight loss treatments, including medications, programs, and surgeries.
General Exclusions and Limitations
Many insurance plans, including some Aetna plans, specifically exclude services and supplies related to the treatment of obesity or for diet and weight control. Under these plans, claims for weight reduction medications and physician supervision of weight reduction programs may be denied. It's essential to carefully review your insurance plan's benefit description to understand any specific exclusions or limitations related to weight loss treatments.
Weight Reduction Counseling
Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m2).
Weight Reduction Medications
Many Aetna benefit plans specifically exclude coverage of weight reduction medications under the pharmacy benefit and/or under the health benefits plan. The medical necessity criteria set forth below do not apply to health plans that specifically exclude services and supplies for or related to treatment of obesity or for diet or weight control. Weight reduction medications should be used as an adjunct to caloric restriction, exercise, and behavioral modification, when these measures alone have not resulted in adequate weight loss. Weight loss due to weight reduction medication use is generally temporary. In addition, the potential for development of physical dependence and addiction is high. Individuals who cannot maintain weight loss through behavioral weight loss therapy and are at risk of medical complications of obesity are an exception to this; for these persons, the risk of physical dependence or other adverse effects may present less of a risk than continued obesity. Tests with weight loss drugs have shown that initial responders tend to continue to respond, while initial non-responders are less likely to respond even with an increase in dosage. If a person does not lose 2 kg (4.4 lbs) in the first four weeks after initiating therapy, the likelihood of long-term response is very low.
Specific Weight Loss Medications and Insurance Coverage
Several weight loss medications are available, each with its own set of criteria for use and insurance coverage. Here's a look at some common medications:
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Didrex (benzphetamine hydrochloride)
Didrex tablets contain the anorectic agent benzphetamine hydrochloride. Didrex is indicated in the management of exogenous obesity as a short term (a few weeks) adjunct in a regimen of weight reduction based on caloric restriction in patients with an initial body mass index (BMI) of 30 kg/m2 or higher who have not responded to appropriate weight reducing regimen (diet and/or exercise) alone. Didrex is contraindicated in patients with advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension, hyperthyroidism, known hypersensitivity or idiosyncrasy to sympathomimetic amines, and glaucoma. Benzphetamine should not be given to patients who are in an agitated state or who have a history of drug abuse. Hypertensive crises have resulted when sympathomimetic amines have been used concomitantly or within 14 days following use of monoamine oxidase inhibitors. Didrex should not be used concomitantly with other CNS stimulants. Didrex may cause fetal harm when administered to a pregnant woman. Didrex is contraindicated in women who are or may become pregnant. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. Didrex should not be used in combination with other anorectic agents, including prescribed drugs, over-the-counter preparations and herbal products. Valvular heart disease associated with the use of some anorectic agents such as fenfluramine and dexfenfluramine has been reported. Possible contributing factors include use for extended periods of time, higher than recommended dose, and/or use in combination with other anorectic drugs.
Contrave (naltrexone and bupropion)
Contrave is a combination of naltrexone, an opioid antagonist, and bupropion, an aminoketone antidepressant, indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of: 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia).
Orlistat (Xenical, Alli)
Orlistat is a reversible inhibitor of gastric and pancreatic lipases. Binding of orlistat to these enzymes forms inactive intermediates in the gut. This non‐systemic action does not allow fat to be broken down and absorbed. Rather, an oil phase that includes triglycerides and cholesterol is excreted in feces. This effect may lead to weight loss. Xenical (orlistat) is indicated for obesity management including weight loss and weight maintenance when used in conjunction with a reduced‐calorie diet. It is also indicated to reduce the risk for weight regain after prior weight loss. Orlistat is available as Xenical in 120mg capsules and as Alli in 60mg capsules. Alli is available over‐the‐counter. Recommended dosage of Xenical is one 120-mg capsule three times a day with each main meal containing fat (during or up to 1 hour after the meal). Supplementation with fat‐soluble vitamins (A, D, E, K) and beta carotene is recommended in some patients as these may not be adequately absorbed when given orlistat therapy. Comorbidities associated with obesity appear to be improved through weight loss in orlistat treated patients. Other than orlistat (Xenical), which is approved for use in adolescents aged 12 years or older, weight reduction medications have not been proven to be safe and effective for treatment of obesity in children and adolescents. Orlistat (Xenical) is contraindicated in persons with chronic malabsorption syndromes and cholestasis.
Qsymia (phentermine and topiramate)
Qsymia is a combination of phentermine, a sympathomimetic amine anorectic, and topiramate extended-release, an antiepileptic drug, indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of: 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity such as hypertension, type 2 diabetes mellitus, or dyslipidemia. Qsymia (phentermine and topiramate) is contraindicated in pregnancy, glaucoma, hyperthyroidism, hypersensitivity to sympathomimetic amines, and within 14 days of taking monoamine oxidase inhibitors.
Belviq (lorcaserin)
Belviq (lorcaserin) is contraindicated in pregnancy. Belviq was approved in June 2012 by the FDA as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related co-morbid condition, and was launched in the United States in June 2013. Food and Drug Administration (FDA), based on the Agency’s completed analysis of data from the CAMELLIA-TIMI 61 trial. CAMELLIA-TIMI 61 was a randomized, double-blind, placebo-controlled clinical trial to study approximately 12,000 men and women over five years with established cardiovascular disease or at high risk for cardiovascular disease. The study aimed at evaluating long-term cardiovascular and metabolic safety and efficacy of lorcaserin as part of a post-marketing requirement by the FDA. Although in this trial lorcaserin facilitated sustained weight loss without a higher rate of major cardiovascular events than that with placebo, the FDA reviewed that data and concluded that the potential risks of lorcaserin outweigh its benefits. More specifically, the FDA noted there was a numerical imbalance in the number of patients with malignancies. FDA's analysis of the study found that during the course of the trial, 462 (7.7 percent) patients treated with lorcaserin were diagnosed with cancers compared to the placebo group, in which 423 (7.1 percent) patients were diagnosed with cancers (Eisai, 2020). In addition, there were more reports of severe hypoglycemia among patients taking lorcaserin than placebo (0.4 percent vs 0.1 percent) (Echouffo Tcheugui and Ahima, 2019). The FDA’s February 13, 2020 Drug Safety Communication advised patients to stop taking Belviq and Belviq XR and talk to their health care professional about alternative weight-loss medications and weight management programs (Eisai, 2020).
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Liraglutide (Saxenda)
The FDA approved liraglutide [rDNA origin] injection (Saxenda), a once-daily injection of a glucagon-like peptide-1 (GLP-1) receptor agonist, for chronic weight management (Novo Nordisk, 2014). The FDA approval of liraglutide was based upon the SCALE (Satiety and Clinical Adiposity−Liraglutide Evidence in Non-diabetic and Diabetic adults) phase 3 clinical trial program, which included study participants who have obesity (BMI ≥30 kg/m2) or who are overweight (BMI ≥27 kg/m2) with comorbidities (Novo Nordisk, 2014). The SCALE phase 3 clinical trial program of the safety and effectiveness of liraglutide for chronic weight management included three clinical trials that included approximately 4,800 obese and overweight patients with and without significant weight-related conditions (FDA, 2014). Results from a clinical trial that enrolled patients without diabetes showed that patients had an average weight loss of 4.5 percent from baseline compared to treatment with a placebo at one year (FDA, 2014). In this trial, 62 percent of patients treated with liraglutide lost at least 5 percent of their body weight compared with 34 percent of patients treated with placebo. Results from another clinical trial that enrolled patients with type 2 diabetes showed that patients had an average weight loss of 3.7 percent from baseline compared to treatment with placebo at one year. The FDA approved labeling states that patients using liraglutide should be evaluated after 16 weeks to determine if the treatment is working (Novo Nordisk, 2020). Saxenda is a glucagon-like peptide-1 (GLP-1) receptor agonist and should not be used in combination with any other drug belonging to this class, including Victoza, a treatment for type 2 diabetes. Saxenda and Victoza contain the same active ingredient (liraglutide) at different doses (3 mg and 1.8 mg, respectively). Saxenda has a boxed warning stating that liraglutide causes thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Saxenda causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors has not been determined. Saxenda is contraindicated in patients with a personal or family history of MTC or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
Injectable medications (Semaglutide, Tirzepatide)
Mounjaro (tirzepatide) and Ozempic (semaglutide) are often praised on social media for helping people lose weight. However, those drugs are only FDA-approved to treat type 2 diabetes (along with diet and exercise), not obesity. While some providers may prescribe them off-label for other conditions like obesity, they usually aren’t covered by insurance unless a person has a type 2 diabetes diagnosis. Some employers choose to exclude GLP-1 drugs from employer-sponsored health plans. Some insurance plans require prior authorization before approval. It is up to each insurer and its chief medical officer to decide if these medications will be covered. The FDA recently approved versions of GLP-1 medication - including Wegovy (semaglutide), Saxenda (liraglutide), and Zepbound (tirzepatide) - for chronic weight management. According to the FDA, these prescriptions are meant to be used along with a reduced-calorie diet and exercise to manage weight and reduce the risks of obesity-related conditions. However, your health insurer may not cover these drugs unless you have an obesity-related medical problem, such as high cholesterol or high blood pressure. A high BMI that indicates you are obese or overweight may not be sufficient. According to the KFF and the Institute for Clinical and Economic Review (ICER), some injectable drugs intended for weight management can cost $1,300 or more for a month’s supply.
Other Considerations
- Herbal and Natural Treatments: While some studies suggest potential benefits of medicinal plants and natural treatments for diabetes and weight management, scientific evidence is often incomplete.
- Capsaicinoids: Some research suggests that capsaicinoids, found in chili peppers, may help support weight management by reducing energy intake.
Weight Loss Surgery and Insurance Coverage
Insurance coverage for weight loss surgery varies according to the insurance carrier. Those that cover bariatric, or weight loss, surgery often limit their coverage to certain types of surgery. Insurance companies that cover bariatric surgery have varying requirements. Some may require medical records documenting that you have medical problems caused by your weight or records of your participation in medically supervised weight loss programs. In fact, many insurers require at least six months’ participation in a supervised weight loss program within two years of your proposed surgery date.
Steps to Take Before Surgery
Call your insurance carrier: Make sure your plan provides coverage for weight loss surgery and that you have covered benefits for morbid obesity surgery. Policies can change daily. Regardless of your insurance carrier, call to check your coverage.
Document the conversation: Write down the name of the person you speak with, including first name, last name, and direct phone number.
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Understand the codes: Your insurance carrier may request the name of the surgery and the CPT/ICD-9 codes. Insurance companies use the following codes to identify the type of procedure or surgery:
- Lap Gastric Bypass: 43644
- Lap Gastric Sleeve: 43775
- Lap Gastric Banding: 43770
- Diagnosis Code (ICD-10) for Morbid Obesity: E66.01
Allow time for authorization: When you have a surgery date, it may take another two weeks to two months to obtain approval from your insurance carrier.
Insurance Appeals
In almost all instances in which your insurance plan denies preauthorization for your surgery, you have a right to appeal that denial. Appeals can be filed by you as a plan member, or you can appoint someone to assist you.
Navigating Denials and Appeals for Weight Loss Injections
If your doctor prescribed medication but your insurer denied coverage, you have the right to appeal your health plan’s denial of benefits for covered services that you and your health care provider (doctor, hospital, etc.) believe are medically necessary. There are two kinds of appeals - internal appeal and external review.
Weight Loss Clinics and Programs
Many weight loss clinics and programs offer comprehensive approaches to weight management, including medical evaluations, medication prescriptions, nutrition counseling, and exercise plans. These programs can be valuable resources for individuals seeking to lose weight and improve their health.
Coverage for weight loss clinics
- Some clinics accept most major insurance plans.
- Clinics may offer online medical weight loss programs with video visits and prescription delivery to your pharmacy.
- Teams of certified obesity specialists may perform initial medical evaluations to assess your medical condition and determine what medications may be appropriate for you.
Services Offered
- Personalized medical weight loss programs designed to provide a comprehensive approach to weight management, combining customized diet and exercise plans with guidance on physical activity and healthy lifestyle habits.
- Nutrition counseling by nutritionists specializing in weight management who help you implement diet and lifestyle changes.
- Customized weight loss options tailored to your unique needs.
- Guidance and support from healthcare professionals, creating a structured approach that may include portion control, proper nutrition, and strategies to help you stay on track.
Additional Considerations
- Very-Low-Energy Diets (VLED): Evidence supports the safe use of VLEDs for up to 3 months in supervised conditions for patients who fail to meet a target weight loss using a standard low-fat, reduced-energy approach.
- Indirect Calorimetry: Some weight management programs use indirect calorimetry to set energy goals, which may lead to greater weight loss compared to standard care methods.
- DEXA and Bio-impedance: Available evidence does not support the use of whole body DEXA for managing obesity, and there is currently no established role for whole body bio-impedance for weight reduction or other indications.