Will My Health Insurance Cover Gastric Bypass Surgery?

Every health insurance company writes its own criteria for coverage of bariatric or weight loss surgery making it a bit challenging to determine whether your insurance company will cover you. To make it even more challenging, these policies and guidelines change frequently. Many surgical offices employ their own insurance specialists that will work directly with insurance companies to find out exactly what parts of a procedure are covered. They will also make sure that the necessary paperwork has been submitted and do what they can to expedite the approval process. Many offices will also tell you what is not covered and what the out of pocket costs will be for the procedure.

Usually the first step is for a physician to verify that gastric bypass surgery is medically necessary. While surgeons have established certain criteria that determine medical necessity, insurance companies are more or less free to use their own criteria for purposes of payment. In general, insurance companies follow the same guidelines: BMI above 40 (35 when associated with an obesity-related disease), obesity lasting for a significant amount of time and evidence of a physician supervised attempt at non-surgical weight loss that has failed. Generally a letter needs to be drafted by a surgeon or physician and should contain sufficient information about your struggles with weight and associated health problems. It should be clear and concise but also have all of the pertinent information. Any disease that you have that is associated with obesity should be included, regardless of your current Body Mass Index or weight. The letter should include how the obesity is impacting your daily activities and the medications that you are using to correct these obesity-related diseases. If you have had a major event such as heart attack, stroke or transient ischemic attack (sometimes wrongly called a “mini-stroke”) this certainly needs to be included in this first letter. No bit of information is too small; if you have been part of a gym then you should provide your physician with a copy of the receipts as well of any evidence of your workout regimen, such as a journal. If you have participated in a diet program, especially one that provides you with pre-prepared meals, receipts for these programs should be included as well. It may be helpful for your surgeon and general physician to both provide separate letters to your insurance company with similar information describing how gastric bypass surgery is medically necessary for you.

 

 

Understand that there may be certain exclusions written into your health insurance policy that automatically disqualify you from coverage—even if the surgery is medically necessary. Little can be done on a case by case basis, by patient interest groups are working to limit exclusions on all health insurance policies.

 

It is in the interest of the bariatric surgeon to work to have your gastric bypass surgery covered by your health insurance company. They realize that gastric bypass surgery may not occur of your health insurance does not help, at least in part. Therefore, many offices will fight both for pre-authorization and reimbursement. In larger surgical practices there may be a case manager whose sole job is to work with insurance companies, receive approval and benefits on behalf of their patients.