Weight Loss Surgery
Will my insurance cover weight loss surgery?
As obesity is recognized as a disease, medical treatment of the condition can be covered by most insurance plans and Medicare, provided 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 35-40, 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, if accompanied by obesity-induced physical problems that interfere with your lifestyle, may also be considered (i.e., obesity prohibits a person from being treated for joint disease, or body size problems preclude or severely interfere with 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.
Weight Loss Medication
Does insurance cover weight loss medication?
Coverage depends on your insurer; currently, Medicaid and Medicare do not include weight loss medication. While there are low-cost alternatives, they may only be suitable for some.
Even if your insurance covers weight loss medication, obtaining approval can be challenging and may hinge on your health status. That’s why the Bariatric Care Center at Ellis has a dedicated full-time staff member for insurance appeals, ensuring you receive the comprehensive coverage you deserve. We’ll also collaborate with you to assess out-of-pocket costs.
Qualifications for Medication Weight Loss:
- BMI of 30 or more or a BMI between 27 and 30 with qualifying comorbidity
- Poorly controlled hypertension, diabetes, or sleep apnea
- Medication may be used to assist preoperative weight loss goals
- Note: Insurance coverage and national medication supply issues may affect participation in medically managed weight loss programs.
Important Questions
Here are some important questions to ask your insurance carrier before undergoing bariatric care:
- Are these bariatric services covered 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 a 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 the date of your conversation.
Financing Option for Bariatric Care
Even if your insurance doesn’t cover the cost of bariatric care, there may be financing options available. The Bariatric Care Center at Ellis Medicine 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.