For individuals struggling with weight loss through traditional methods like diet and exercise, medical weight loss programs offer a path forward. These programs involve the expertise of healthcare providers and may include interventions like behavioral counseling, medication, or even surgery. A significant concern for many considering these options is the cost and whether their insurance will provide coverage. The short answer to whether medical weight loss programs are covered by insurance is that it varies, depending on the treatment provided, the way the offering is set up, and your insurance.
Understanding Medical Weight Loss
Medical weight loss involves leveraging the expertise, guidance, and support of a physician or a team of healthcare providers for weight loss efforts. This often includes behavioral interventions and counseling, which could be provided by a registered dietitian or medical provider such as a physician, physician assistant, or nurse practitioner. It may also include the use of FDA-approved weight loss medication, bariatric surgery, or medical weight loss devices as appropriate.
Insurance Coverage for Obesity Treatment
In 2013, the American Medical Association designated obesity as a chronic disease requiring prevention and treatment. This decision was based on mounting evidence that obesity is a complex condition influenced by biology, environment, and behavior, and that it can lead to other serious health conditions such as type 2 diabetes, heart disease, stroke, and many cancers. As a result of this designation and the high prevalence of obesity, there have been significant advances in treatment options for helping people to lose weight and keep it off. Despite all of these advancements, affordability of care remains a barrier to many patients seeking treatment.
Types of Weight Loss Treatments Potentially Covered
Insurance coverage of obesity treatment will vary depending on your state and insurance plan. Treatment options that may be eligible for reimbursement include:
- Behavioral Intervention and Counseling
- Weight Loss Medication(s)
- Bariatric Surgery
- Medical Weight Loss Devices
Behavioral Intervention and Counseling
Changing behaviors around diet and physical activity are an important component of any weight loss program, as are ongoing support and accountability. The extent and frequency of counseling sessions can vary significantly depending on the type of provider or provider(s) you see for weight management. Such treatment may be guided by a physician or other medical provider, but could also be provided by a Registered Dietitian or psychologist. Some weight loss programs provide a multidisciplinary approach using a combination of medical providers, dietitians, and/or psychologists.
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Under the Affordable Care Act, insurance providers are required to cover “obesity screening and counseling”. But there is no further guidance as to how often you can see your medical provider for counseling or if you can see another provider such as a Registered Dietitian or psychologist. Coverage of these services is going to vary from state-to-state and depend on your particular insurance plan. The best way to know what is covered is to check your plan documents or contact your insurance carrier to get more information.
Weight Loss Medications
When comprehensive behavioral intervention and counseling aren’t enough, FDA-approved weight loss medication may be recommended. These medications are not appropriate for all patients though. Prescription weight loss medication is indicated for persons with a body mass index (BMI) ≥ 27 kg/m2 with a weight-related medical problem or a BMI ≥ 30 kg/m2 who have not responded to more conservative treatment. Additionally, medications are not safe for all persons, so a thorough review of your health history and the current medications you’re taking is important in determining if weight loss medication is right for you.
When it comes to coverage, there is no clear answer to the question “Is weight loss medication covered by insurance?”. It really varies depending on the medication being prescribed and your insurance benefits. Working with a provider who specializes in obesity medicine can help you to work through some of the nuances of insurance coverage as they are familiar with completing prior authorization requests and can discuss alternative options if the medication prescribed is not covered by your plan.
Several FDA-approved medications are used for weight management. Liraglutide [rDNA origin] injection (Saxenda), a once-daily injection of a glucagon-like peptide-1 (GLP-1) receptor agonist, is approved for chronic weight management. 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.
Other medications include:
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- Contrave: A combination of naltrexone and bupropion, used as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with specific BMI criteria.
- Orlistat (Xenical, Alli): A reversible inhibitor of gastric and pancreatic lipases that reduces fat absorption. Xenical requires a prescription, while Alli is available over-the-counter.
- Qsymia: A combination of phentermine and topiramate, used as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults meeting specific BMI criteria.
- Didrex: 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.
It's important to note contraindications and potential side effects associated with each medication. For example, Saxenda has a boxed warning regarding thyroid C-cell tumors, and Qsymia is contraindicated in pregnancy. Belviq (lorcaserin) was previously approved but was later withdrawn from the market due to safety concerns.
Bariatric Surgery
Bariatric surgery is the most effective treatment for severe obesity, helping patients lose 20-30% of their initial body weight. Surgery is indicated for persons with a BMI ≥ 35 kg/m2 with a weight-related medical problem or a BMI ≥ 40 kg/m2. Surgical procedures include gastric banding, Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and duodenal switch. The decision to pursue bariatric surgery and the most appropriate procedure should be discussed at length with a healthcare provider who specializes in obesity medicine and/or bariatric surgery. Additionally, a long-term commitment to a healthful diet and regular physical activity are necessary for success and safety following bariatric surgery, so finding a team to assist with establishing and maintaining those habits is an important part of the process. Sometimes, certain weight loss medications can be used alongside gastric bypass surgery.
Coverage of bariatric surgery has improved in the last decade as 23 states have a specific health benefit requirement for the coverage of bariatric surgery. Additionally, Medicare and most Medicaid plans cover this treatment option. If you have private health insurance, coverage will depend on your state laws and benefit plan, so it is best to contact your insurance carrier for more information.
Medical Weight Loss Devices
Medical devices used to assist weight loss are relatively new to the treatment toolbox. Just like with medications and bariatric surgery, they are meant to be used in a combination with a reduced-calorie diet, increased physical activity, and behavior changes that promote weight loss and are for patients who have not responded to more conservative treatment approaches.
Some FDA-approved devices for obesity treatment include the following:
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- Laparoscopic gastric band: An adjustable band placed around the stomach that can be inflated to make the stomach smaller with the intention of decreasing food intake. Insurance that covers bariatric surgery will generally cover the cost of a gastric band.
- Intragastric balloon: A gas- or liquid-filled balloon swallowed or placed inside the stomach and meant to occupy space to promote a sensation of fullness. Unfortunately the intragastric balloon is not usually covered by health insurance.
- PlenityⓇ: Capsules filled with hydrogel particles and swallowed prior to meals in order to absorb water and occupy space in the stomach, leading to reduced food intake.
Checking Your Insurance Coverage
Navigating insurance coverage can be complex, but resources are available to help:
- Check Cost and Coverage Tools: Platforms like the one from Novo Nordisk for Wegovy® can help you check your insurance coverage. You'll be asked to provide information about yourself, your insurance, and your healthcare professional.
- Prior Authorization: If your insurance requires prior authorization, your healthcare professional will need to submit a form to the insurance company for approval.
- Appeals and Requests: If your coverage is denied, you may have the option to submit an appeal or request for coverage with the help of your healthcare professional.
- Contact Your Insurance Carrier: The most direct way to understand your coverage is to check your plan documents or contact your insurance carrier to get more information.
Additional Programs and Considerations
- Real Appeal®: Some health plans, like UnitedHealthcare, offer programs like Real Appeal®, which may be covered at 100% for eligible members. These programs often include a success kit with tools like a body weight scale and access to fitness resources.
- Aetna: It's important to note that some Aetna plans may specifically exclude services and supplies for the treatment of obesity or for diet and weight control.
Lifestyle and Dietary Approaches
In addition to medical interventions, lifestyle and dietary approaches play a crucial role in weight loss. The Center for Weight Management and Wellness at Brigham and Women’s Hospital offers personalized plans that can be adapted to individual goals and food preferences. These plans include:
- Healthy Eating, Calorie Controlled Plan: Focuses on consuming healthy foods purchased independently, guided by a dietitian.
- Meal Replacement Plan: Involves replacing some meals with liquid meal replacement shakes, along with healthy foods.
- All Meal Replacement Plan: Replaces all meals with liquid meal replacement shakes for comprehensive nutrition and weight loss.
- Medication-Assisted Weight Loss Plan: Combines the Calorie Controlled Plan with an FDA-approved prescription medication for weight loss.
These programs also incorporate group sessions for skill-building and long-term weight loss maintenance.
The Importance of a Multidisciplinary Approach
Successful weight loss often requires a multidisciplinary approach involving physicians, dietitians, psychologists, and other healthcare professionals. These teams can provide comprehensive support and guidance to help individuals achieve their weight loss goals and maintain a healthier lifestyle.