The journey to managing weight and achieving a healthier lifestyle often involves seeking professional guidance from weight loss clinics. However, understanding insurance coverage for these services can be complex. This article aims to clarify the landscape of weight loss clinic insurance coverage, providing insights into what to expect and how to navigate the process.
Understanding Insurance Coverage for Weight Loss Programs
Many health insurance plans offer coverage for obesity screening and counseling as part of the Affordable Care Act. These plans, including those purchased through the Health Insurance Marketplace, typically include these benefits without copays or deductibles. During a physical examination, a doctor will assess weight and height to calculate the body mass index (BMI). A BMI of 25 or higher indicates overweight, while a BMI of 30 or more signifies obesity.
If a doctor determines that an individual meets the medical guidelines for obesity, counseling sessions on diet and weight reduction may be recommended. These sessions can be conducted individually or in a group setting, such as Weight Watchers. The goal of these counseling sessions is to help individuals adopt healthier eating and exercise habits, which can lead to weight loss and a reduced risk of associated health problems.
Limitations and Variations in Coverage
It's important to note that the specific details of obesity counseling coverage can vary significantly from plan to plan. The Affordable Care Act does not provide an exact definition of what obesity counseling must include. Therefore, it is essential to contact the insurance provider directly to understand the specific coverage details. If insurance is obtained through an employer, the human resources department can also provide information on the policy's coverage.
Grandfathered health plans, which existed before the Affordable Care Act and have not undergone significant changes, are not required to offer weight loss counseling. Short-term health plans also may not offer these benefits.
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Aetna's Coverage Policies
Aetna, a major health insurance provider, has specific policies regarding weight loss services. Many Aetna plans explicitly 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 will be denied.
However, Aetna considers up to 26 combined individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (BMI ≥ 30 kg/m2). It is important to check the specifics of your Aetna plan to confirm coverage details.
Weight Loss Medications and Insurance
Weight reduction medications are often considered as an adjunct to caloric restriction, exercise, and behavioral modification when these measures alone have not resulted in adequate weight loss. However, many Aetna benefit plans specifically exclude coverage of weight reduction medications under the pharmacy benefit and/or under the health benefits plan.
Considerations for Weight Reduction Medications
Weight loss due to weight reduction medication use is generally temporary. The potential for developing 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 may be an exception. For these individuals, the risk of physical dependence or other adverse effects may be less significant than continued obesity.
Clinical experience suggests that individuals who respond well to weight loss drugs initially tend to continue responding, while those who do not respond initially are less likely to respond even with an increase in dosage. It is recommended that 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.
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Specific Weight Loss Medications
Several weight loss medications are available, each with its own indications, contraindications, and potential side effects:
- Didrex (benzphetamine hydrochloride): Indicated for short-term management of exogenous obesity in patients with a BMI of 30 kg/m2 or higher who have not responded to diet and/or exercise alone. It is contraindicated in patients with advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension, hyperthyroidism, hypersensitivity to sympathomimetic amines, and glaucoma. It should not be used in pregnant women or in combination with other CNS stimulants or anorectic agents.
- Contrave (naltrexone and bupropion): Indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with a 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.
- Orlistat (Xenical, Alli): A reversible inhibitor of gastric and pancreatic lipases that reduces fat absorption. Xenical (120mg) is available by prescription, while Alli (60mg) is available over-the-counter. It is indicated for obesity management, including weight loss and weight maintenance, when used with a reduced-calorie diet. It is contraindicated in persons with chronic malabsorption syndromes and cholestasis. Supplementation with fat-soluble vitamins is recommended.
- Qsymia (phentermine and topiramate): Indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with a 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. It is contraindicated in pregnancy, glaucoma, hyperthyroidism, hypersensitivity to sympathomimetic amines, and within 14 days of taking monoamine oxidase inhibitors.
- Belviq (lorcaserin): 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 specific BMI criteria and comorbidities. However, the FDA requested the manufacturer to withdraw Belviq from the market in February 2020 due to data indicating an increased risk of cancer.
- Liraglutide (Saxenda): A glucagon-like peptide-1 (GLP-1) receptor agonist approved by the FDA for chronic weight management. It is administered as a once-daily injection and is indicated for patients with obesity (BMI ≥30 kg/m2) or who are overweight (BMI ≥27 kg/m2) with comorbidities. It should not be used in combination with other drugs in the same class, such as Victoza.
Injectable Medications for Weight Loss
Injectable drugs containing semaglutide or tirzepatide, which are GLP-1 receptor agonists, have gained popularity for their effectiveness in reducing blood sugar, appetite, and signaling fullness. Mounjaro (tirzepatide) and Ozempic (semaglutide) are FDA-approved to treat type 2 diabetes but may be prescribed off-label for obesity. However, insurance coverage for these drugs is typically limited to individuals with a type 2 diabetes diagnosis.
Wegovy (semaglutide), Saxenda (liraglutide), and Zepbound (tirzepatide) are FDA-approved for chronic weight management when used with a reduced-calorie diet and exercise. Health insurers may cover these drugs if the individual has an obesity-related medical problem, such as high cholesterol or high blood pressure.
Without insurance, injectable drugs for weight management can cost $1,300 or more for a month’s supply.
Appealing Insurance Denials
If an insurance claim for weight loss medication or treatment is denied, there is a right to appeal the decision. The appeals process typically involves two steps: an internal appeal and an external review. The National Association of Insurance Commissioners (NAIC) provides expertise and data to state insurance regulators to help them effectively regulate the industry and protect consumers.
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Medical Weight Management Programs and Bariatric Surgery
Many insurance companies require patients to complete a medically-supervised weight management (MWM) program as a prerequisite for approval for bariatric surgery. These programs typically range from 4 to 6 months and require consecutive monthly documentation of weight and dietary counseling.
However, studies have shown that insurance-mandated MWM programs may not necessarily lead to better postoperative outcomes. Some studies have even suggested that these programs may increase the "drop-out" rate before bariatric surgery.
NYU Langone's Weight Management Program
NYU Langone’s Weight Management Program is recognized as part of several Institutes of Quality Bariatric Surgery Networks, including Aetna, Cigna, Blue Cross Blue Shield, and HIP Emblem. The program assists patients in navigating the insurance authorization process for weight loss surgery.
Steps to Take Before Visiting a Weight Management Program
- Call the insurance carrier to ensure the plan provides coverage for weight loss surgery and that there are covered benefits for morbid obesity surgery.
- Write down the name of the person spoken with, including their first name, last name, and direct phone number.
- Be prepared to provide the name of the surgery and the CPT/ICD-9 codes to the insurance company.
It is important to note that the insurance authorization process can take several weeks to months to complete.
Alternative Approaches to Weight Management
Very-Low-Energy Diets (VLED)
Very-low-energy diets (VLED) can be safely used 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. VLED involves consuming a very low amount of calories, usually through liquid meal replacements. Studies have demonstrated significant weight loss and improvements in blood pressure, waist circumference, and lipid profile in the longer term following a VLED.
Capsaicinoids
Capsaicinoids, found in chili peppers, have bioactive properties that may support weight management. Studies have shown that capsaicinoid ingestion prior to a meal can reduce ad libitum energy intake.
Indirect Calorimetry
Indirect calorimetry can be used to set personalized energy goals for weight management programs. Studies have shown that participants who receive a personalized nutrition energy goal message developed using measured resting metabolic rate (RMR) from a hand-held indirect calorimeter lose significantly more weight than those who receive a nutritional message using a standard care equation.
Real Appeal Program
Real Appeal is a weight loss program offered by UnitedHealthcare. The program includes a Success Kit containing a body weight scale, an electronic food scale, a balanced portion plate, and access to Fitness on Demand. The program is covered at 100% for all eligible UnitedHealthcare health plan members, with no deductibles or co-payments.