Weight Loss Surgery Insurance


One of the biggest hurdles patients face when considering weight loss surgery is figuring out how to pay for it. Insurance companies take a widely variable approach to coverage. Even within the same insurance provider, coverage will vary from policy to policy - sometimes dramatically.

If you and your doctors believe weight loss surgery maybe right for you, the first thing you need to do is check your health insurance policy. Gather as much information about their current standards for approval as you can.

Call your insurance provider and ask questions, being sure to document your conversations. Don't take one customer service representative's word for something: ask to receive material in writing, and call back and speak with several representatives.

While most insurance companies follow the basic guidelines for approval based on current NIH standards (see Qualifying for Weight Loss Surgery), some insurance companies set a higher standard for approval, such as requiring a BMI of more than 50 in some cases.

 Ironically, research indicates that insurers recover their costs for weight loss surgeries in two to four years, making weight loss surgery a cost-saving measure when calculating the health-care costs of those suffering from obesity.(1)

Denied coverage and the overall difficulty of gaining insurance approval for weight loss surgery are cited as the two most common reasons why patients who had considered weight loss surgery decided not to proceed with surgery, according to a recent study.(2)

To help doctors performing weight loss surgery work with insurance companies, medical industry organizations offer guidance, such as placing patients on a 6-month diet prior to surgery, getting support from a multidisciplinary team, providing detailed analysis of each patient indication and documenting the quality of cost-effectiveness and long-term benefits.(3)

To begin the process of applying for insurance approval for weight loss surgery, you should prepare the following information:

-Documented Dieting Attempts
-Documented Exercise Attempts
-Psychological Evaluation
-Medical Records / Letter of Medical Necessity

If you are denied approval for weight loss surgery, be careful to review your application before re-applying. Most insurance companies will hear a fixed number of appeals (usually three), so it's important to use your opportunities to appeal wisely. If you are fortunate enough to get your insurance company to approve your weight loss surgery, you'll still likely have to cover some of the up-front costs yourself, and you'll almost certainly be paying for some post-operative elements. Work out with your doctor exactly what costs you'll be expected to cover, and when that payment is due.

(1) "A Study on the Economic Impact of Bariatric Surgery" American Journal of Managed Care. September 2008
(2) "Refusals, Denials and Patient Choice: Reasons Prospective Patients do not Undergo Bariatric Surgery" Surgery for Obesity and Related Diseases. September 2007; pp531-35
(3) Frezza, EE. "Six Steps to Fast-Track Insurance Approval for Bariatric Surgery" Obesity Surgery. May 2006; 16(5):pp659-63