Weight loss surgery, also known as bariatric surgery, can be a life-changing option for individuals struggling with obesity when exercise, medications, and diet aren't sufficient. However, the financial aspect can be a significant hurdle. This article aims to provide a detailed guide on how to navigate insurance coverage for weight loss surgery, making the process more transparent and manageable.
Understanding the Basics of Insurance Coverage
Insurance coverage for bariatric surgery varies significantly depending on the insurance carrier and the specific plan. Some policies may cover certain types of weight loss surgery, while others may have strict limitations or exclusions. It's crucial to determine whether your policy covers weight loss surgery and understand the specific criteria for approval.
Initial Steps to Take
Before scheduling a consultation with a bariatric surgeon, it's essential to take the following steps:
Contact Your Insurance Carrier: Call your insurance carrier to confirm whether your plan provides coverage for weight loss surgery and if you have covered benefits for morbid obesity surgery. Policies can change frequently, so it's essential to verify coverage regardless of your insurance carrier. Write down the name of the person you speak with, including their first name, last name, and direct phone number for future reference.
Inquire About Specific Codes: Your insurance carrier may request the name of the surgery and the relevant CPT/ICD-10 codes. Common codes include:
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- Lap Gastric Bypass: 43644
- Lap Gastric Sleeve: 43775
- Lap Gastric Banding: 43770
- Diagnosis Code (ICD-10) for Morbid Obesity: E66.01
Understand the Purpose of the Call: Remember that this initial call is for informational purposes only. The formal insurance authorization process should be initiated by your surgeon's office after you have met with the surgeon and scheduled your surgery date. Initiating the authorization process prematurely may lead to the closure of your case by the insurance company.
Qualifying for Bariatric Surgery Coverage
Most insurance companies have specific requirements that must be met to qualify for bariatric surgery coverage. These requirements typically include:
Body Mass Index (BMI) Criteria: A person must have a body mass index (BMI) of 40 or greater, or a BMI of 35 or greater with an obesity-related co-morbid condition.
Co-morbid Conditions: Obesity-related co-morbid conditions may include:
- Diabetes mellitus, Type II
- Cardiovascular disease
- Hypertension
- Life-threatening cardio-pulmonary problems (e.g., severe obstructive sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy)
Documentation Requirements: Insurance companies often require documentation of the following:
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- Participation in a Weight Loss Program: The individual must have actively participated in a medically supervised weight loss program for at least 3-6 months within two years of the proposed surgery date. Insurers often require at least six months' participation in a supervised weight loss program. Note that insurance companies typically do not recognize "fad diet plans" such as Weight Watchers, Overeaters Anonymous, Nutri-systems, or gym memberships. They are looking for documentation of regular follow-up visits with a doctor or nutritionist where you were counseled on weight loss.
- Pre-operative Medical and Mental Health Evaluations and Clearances
- Pre-operative Nutritional Counseling with a Registered Dietitian
- Pre-operative Education: Addressing the risks, benefits, realistic expectations, and the need for long-term follow-up and adherence to behavioral modifications.
Medical Necessity: Most major insurance companies require proof that surgery or medical intervention is medically necessary. Your surgeon can provide your medical history and documentation of your weight-related health problems.
Physician-Supervised Diet Program: You may be required to successfully complete a 6-month weight-loss program before approval is granted. The insurance companies aren’t trying to find out if you can lose weight through dieting. In fact, most insurance companies require that the patient's weight be stable during this time -- with no up-and-down fluctuations -- or you may be denied coverage. They want you to demonstrate over the 6 months prior to surgery that you can commit to lifestyle changes you’ll need to make forever after your weight loss surgery.
Psychological Evaluation: This evaluation ensures that you understand weight loss surgery and the impact it will have on your lifestyle. It also checks for untreated binge eating or any other psychological issues.
Nutritional Evaluation: You will work one-on-one with a nutritionist to outline specific dietary changes and habits that need to be changed.
The Authorization Process
Once you have met with the surgeon and scheduled a surgery date, the formal insurance authorization process can begin. This process typically involves the following steps:
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Surgeon's Preauthorization Request: Your surgeon will send a preauthorization request letter to your insurance company, outlining your medical history, health problems related to your weight, and documentation that you have completed all requirements for approval.
Insurance Company Review: The insurance company will review your case. They may request specific diagnostic tests, such as cardiac, pulmonary, or sleep apnea evaluations, if you have symptoms of weight-related conditions.
Timeline: It can take anywhere from two weeks to two months to obtain approval from your insurance carrier after you have a surgery date.
Documentation: During this period, keep accurate notes of all communications between the insurance company and your surgeon. Keep copies of completed insurance forms, letters sent, and letters received.
Appealing a Denial
In almost all instances in which your insurance plan denies preauthorization for your surgery, you have a right to appeal that denial. If your request is turned down, or if the insurance company agrees to pay only a small percentage of the cost, the door is not closed. You can write a letter of appeal to the insurance company representative (such as a claims supervisor) who signed the denial. Before you appeal, make sure you understand your policy completely, and that it does not specifically exclude the weight loss surgery you want. Also, make sure restrictions were not in place when you first began your contract with the health plan.
Steps to Take When Appealing
Understand Your Policy: Before you appeal, make sure you understand your policy completely and that it does not specifically exclude the weight loss surgery you want. Also, make sure restrictions were not in place when you first began your contract with the health plan.
Craft a Strong Appeal Letter: Your appeal letter should include:
- An explanation of why you feel the procedure should be covered.
- A request for a full explanation of why coverage is being denied (or paid at a reduced level).
- A request for a copy of the specific statement -- taken from the policy or benefits booklet -- that explains why your coverage is limited or denied.
- A copy of the denial notification.
- A copy of your doctor's preauthorization request letter.
Seek External Assistance: You may find it helpful to send a copy of your appeal letter to your state's insurance commissioner or the department of corporations if you are covered by an HMO plan. You can explain that you’re having trouble and ask for assistance. Your bariatric surgeon can also help you with your appeal.
Addressing Coverage Gaps and Financial Considerations
Even with insurance coverage, you may still face out-of-pocket costs such as deductibles, co-pays, and coinsurance. Understanding these costs and exploring financing options is essential.
Options When Insurance Doesn't Cover Surgery
You have several options from which to choose if your insurance company does not cover or approve your surgery.
Switch Insurance Carriers: Consider switching to another insurance carrier during open enrollment.
Cash Payment: Pay cash for your weight loss surgery without insurance. Our financial care counselors can give you estimates of what procedures will cost. Please note that payment is required in full before the procedure can be performed.
Financing Options: If you do not have health insurance, or if your insurer will not cover weight loss surgery, talk to your doctor and your surgeon about financing plans. Some weight loss surgery centers can help you get a loan that you can repay over a number of years.
Cost Factors
Weight loss surgery is expensive. Typical costs can run from $20,000 to $25,000, according to the National Institute of Diabetes and Digestive and Kidney Diseases. The price of your weight loss surgery will depend on several factors:
- The type of surgery you're having. Types of weight loss surgery include gastric bypass, adjustable gastric banding, vertical gastric banding (also called stomach stapling), sleeve gastrectomy, and biliopancreatic diversion. Other options include intragastric balloons or even an electric Implant device. Each has a different fee.
- Your surgeon's fee. This will vary based on where you live, your surgeon's expertise, and the procedure’s complexity.
- The hospital or facility you choose. Costs will vary and may include the operating and hospital rooms, among other fees.
Additional costs may include:
- Anesthesiologist's fee
- Surgical assistant's fee
- Device fees
- Consultant fees (if necessary)
- Follow-up procedures (for the gastric band)
State Mandates and the Affordable Care Act
Under the Affordable Care Act, some states require that health insurers selling plans in the Marketplace or directly to individuals or small groups cover bariatric surgery; by 2016 nearly half of states mandated coverage for these plans. However, it's important to note that Essential Health Benefits are determined in each state based on a health insurance plan that legislators find to be the most representative of the “average” plan in the state. Unfortunately, in the state of Florida insurance companies are NOT required to include weight loss surgery through Affordable Healthcare Act. Therefore, if you live in Florida and have health coverage through Affordable Care Act obesity surgery is not covered.
Medicare and Medicaid Coverage
Medicare covers bariatric surgery as long as all the necessary medical criteria are met and documented. Potential patients must have a minimum body mass index (BMI) of 35 or greater with at least 2 complicating co-morbid condition. Medicare will require a history of obesity (5 years if obtainable), office notes where a physician has counseled you on the need for weight loss, a letter of medical necessity from your primary care doctor, and psychological and nutritional evaluations (coordinated through the office). Medicare also requires patients to be smoke fee for a minimum of 6 weeks prior to the surgery.
Seeking Professional Guidance
Navigating the complexities of insurance coverage for weight loss surgery can be overwhelming. Consulting with financial care counselors or insurance advocates can provide valuable assistance in understanding your policy, navigating the authorization process, and appealing denials.