Will my insurance cover weight loss surgery?
Obesity is now recognized as a disease, so medical treatment of the condition can be covered by most insurance plans and Medicare, providing you meet the requirements to qualify for surgical care. (Please note: Coverage may vary by health insurance plan, so always check with your provider. Although we participate with most insurance plans, please be aware that regardless of your policy, you will be financially responsible for all non-covered services.)
Requirements for bariatric surgery:
- A Body Mass Index (BMI) of 40 or more (at least 100 pounds over ideal weight).
- A BMI between 35 and 40, if accompanied by a high-risk comorbid condition such as life-threatening cardiopulmonary problems (i.e., severe sleep apnea, Pickwickian syndrome, and obesity-related cardiomyopathy) or severe diabetes mellitus.
- A BMI of 35-40 who also has obesity-induced physical problems that interfere with lifestyle may also be considered (i.e., obesity prohibits a person from being treated for a joint disease, or body size problems preclude or severely interfere with ones employment, family function and/or ability to walk).
It’s always important to check with your health insurance provider to confirm what aspects of care qualify for coverage under your plan. For managed care and HMO patients, please remember to obtain the required approvals and referrals when necessary from your primary care physician throughout the bariatric surgery process.
Here are some of important questions to ask your insurance carrier before undergoing bariatric care:
- Are these bariatric services covered benefit under my policy?
- Gastric Bypass CPT code 43644
- Gastric Sleeve CPT Code 43775
- Dietitian Visit CPT Code 97802
- Do I need to go to a Center of Blue Distinction?
- Do I have any bariatric exclusions or limitations on my policy?
- Are there special requirements such as 3 or 6 month medically supervised weight loss program prior to surgery?
- Is Ellis Medicine in network or out of network?
- If my surgeon is out of network, am I still covered and what is my financial responsibility?
- What percentage of the surgery is covered by my plan?
- What is my yearly deductible? Have I met it? If not, how much do I have to pay out of pocket before I meet my deductible?
- What is my maximum out of pocket expense?
- What is my specialist co-pay amount?
- Is a referral required?
Note: we recommend you record the answers, along with your insurance representative’s name and date of your conversation.
Financing options for bariatric care
Even if your insurance doesn’t cover the cost of bariatric care, there may be financing options available. Ellis Medicine Bariatric Care Center has established a relationship with local financial partners to help prospective patients finance the cost of their care, and spread out the payments into monthly payments.
To learn more about insurance or financing, please call our office at 518.243.1313.