Obesity is a growing global health concern, increasing the risk of serious health problems like heart disease, diabetes, and certain cancers. Weight loss can significantly reduce these risks and lower healthcare costs, leading many insurance companies to offer coverage for weight loss treatments. However, insurance coverage for weight loss treatments varies greatly depending on the insurance carrier and specific plan. This article provides a comprehensive guide to understanding insurance coverage for weight loss treatments, including surgery, medications, and counseling.
Insurance Coverage for Weight Loss Surgery
Insurance coverage for bariatric, or weight loss, surgery varies according to the insurance carrier. Those that cover bariatric surgery often limit their coverage to certain types of surgery. Some insurance companies 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 Visiting a Weight Loss Clinic
Prior to visiting a weight loss clinic, it is essential to take the following steps to understand your insurance coverage:
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, so it is crucial to call and check your coverage regardless of your insurance carrier.
Record the details: Write down the name of the person you speak with, including first name, last name, and direct phone number.
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Inquire about necessary 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
Understand the purpose of the call: Your call to the insurance company should be for informational purposes only. The weight loss clinic will initiate the formal insurance authorization process after you meet with the surgeon and schedule your surgery date.
The Authorization Process
The surgical scheduler at the weight loss clinic cannot initiate the authorization process until you have a surgery date, even if you have already attended the required information session and scheduled appointments with the psychologist and nutritionist. If you initiate your surgery authorization process without having seen the surgeon, your insurance company may close your authorization case. The authorization process can take anywhere from 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. If the insurance plan denies the procedure, filing an appeal is justified. Appeals can be filed by you as a plan member, or you can appoint someone to assist you.
Insurance Coverage for Medical Weight Loss Programs
Each health insurance plan varies in the coverage they offer for medical weight loss programs. Most insurance companies require extensive documentation regarding your past attempts to lose weight, as they determine whether or not to finance your weight surgery.
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Gathering Necessary Records
It is crucial to gather your necessary records as soon as possible, so they are available when you talk with your insurance company. For your weight history outside of the weight loss clinic, you will need to contact the doctor who weighed you and/or prescribed weight-loss drugs for a copy of that documentation. A summary letter from the doctor of dates, weights, medications prescribed, and supervised diets is acceptable. After the weight loss clinic has gathered your weight history, test results, documentation of exercise programs, and other records, they will analyze them and submit a letter of recommendation to your insurance carrier, requesting approval for coverage of the procedure. Some insurance companies will make the decision about your weight loss surgery within a few weeks; some take several weeks or months to return a decision.
Insurance Coverage for Weight Loss Medications
The FDA has approved several medications for chronic weight management, including:
- Liraglutide [rDNA origin] injection (Saxenda)
- Contrave (naltrexone and bupropion)
- Orlistat (Xenical, Alli)
- Qsymia (phentermine and topiramate)
- Belviq (lorcaserin)
However, insurance coverage for these medications varies. Some plans may not cover weight loss medications at all, while others may require prior authorization or have specific criteria for coverage, such as having an obesity-related medical problem like high cholesterol or high blood pressure.
Injectable Weight Loss Medications
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.
Cost of Injectable Drugs Without Insurance
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. While drug manufacturers sometimes offer discount programs, consumers are often left paying hundreds of dollars out of pocket for their prescriptions. Legally, Medicare cannot cover weight loss medications.
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Appealing a Denial of Coverage
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 believe are medically necessary. There are two kinds of appeals - internal appeal and external review.
Affordable Care Act and Obesity Coverage
Most health insurance plans, including all plans purchased through the Marketplace, now include obesity screening and counseling, with no copays or deductibles. When you go in for a physical, your doctor will usually check your weight and height. With those numbers, they can figure out your body mass index, or BMI. A BMI of 25 or higher is overweight. A BMI of 30 or more is obese.
Obesity Counseling
If your doctor finds that you fit the medical guidelines for obesity, you may get counseling sessions on diet and weight reduction. This may include one-on-one meetings, or you may get weight loss advice and support in a group such as Weight Watchers. The counseling sessions can help you change any unhealthy eating and exercise habits. That, in turn, can help you lose weight and lower the chance of health problems. Under the Affordable Care Act, there is no exact definition of what obesity counseling must include. Coverage varies from plan to plan, so call your insurer to see what your policy will cover. If you get insurance through your job, you can also call your human resources department to check.
Diet and Exercise Programs
To help you get back to a healthy weight, your doctor may suggest a diet and exercise program. Most people will want to eat lots of fruits and vegetables, whole grains, and low-fat dairy products. Choose lean meats and foods that are low in unhealthy fats, cholesterol, and added sugars. Exercise helps, too. Work your way up to 30 minutes most days.
Medication and Surgery
If you have a lot of weight to lose, your doctor may suggest medication or surgery. The Affordable Care Act does not require health plans, including those purchased through the Marketplace, to cover this, but some do. Check your plan to see what’s available to you. Your Medicare Part D plan must cover some weight loss drugs if you have both obesity and heart disease or to treat other conditions such as diabetes, but these drugs will not be covered only for those trying to lose weight.
Grandfathered and Short-Term Health Plans
Grandfathered health plans, those that existed before the Affordable Care Act was passed and have not significantly changed, are not required to offer weight loss counseling. Check with your insurance company or HR department to find out if you’re in a grandfathered plan. In addition, short-term health plans do not have to offer these benefits.
Additional Considerations
- Aetna: Many Aetna plan benefit descriptions specifically exclude services and supplies for or related to treatment of obesity or for diet and weight control. Under these plans, claims for weight reduction medications and for physician supervision of weight reduction programs will be denied based on that exclusion. 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/m2Footnotes**). Note: 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.
- Real Appeal: The program, including the Success Kit, is covered at 100% for all eligible UnitedHealthcare health plan members. There are no deductibles or co-payments. While you may see claims processed by your insurance company, there is no additional cost to you. All Real Appeal® Programs include a Success Kit that contains: a body weight scale, an electronic food scale, a balanced portion plate and access to Fitness on Demand through your program dashboard. Each member gets one kit. Your Success Kit will be sent to you once you attend your first live session with your coach. Please allow 7-10 business days for delivery. To enroll, go to the Real Appeal member site and select Enroll Now.
Emerging Trends in Weight Management
Capsaicinoids
Whiting et al (2014) stated that capsaicinoids are a group of chemicals naturally occurring in chili peppers with bioactive properties that may help to support weight management. These investigators conducted a meta-analysis investigating the potential effects of capsaicinoids on energy intake, clarified previous observations and formed evidence-based conclusions about possible weight management roles. Data analysis showed that capsaicinoid ingestion prior to a meal reduced ad libitum energy intake by 309.9kJ (74.0kcal) during the meal (p < 0.001).
Very-Low-Energy Diets (VLED)
Mulholland et al (2012) stated that evidence from the literature supports the safe use of very-low-energy diets (VLED) 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. There is, however, a need for longer-term outcomes on obesity and associated morbidities following a VLED. Current evidence demonstrated significant weight loss and improvements in blood pressure, waist circumference and lipid profile in the longer term following a VLED.
Indirect Calorimetry
McDoniel et al, (2008) evaluated the efficacy of a weight management program using indirect calorimetry to set energy goals. Investigators reported that treatment participants lost significantly more weight than usual care participants (p ≤ 0.05).