For an increasing number of patients, weight-loss surgery can offer a way to improve their health and quality of life. Forecasts predict that the bariatric surgery market will grow at a compound annual growth rate (CAGR) of 9.56% from 2019 to 2028. And with the average cost running between $15,000 to $36,000, insurance coverage is an important consideration for the majority of patients. You can simplify the insurance process for your surgical patients by learning how to get insurance to pay for bariatric surgery.
Read on to know which states require insurance plans to cover bariatric surgery and the typical insurance criteria for bariatric surgery coverage.
- Most insurance covers bariatric surgery. Coverage of bariatric surgery is a requirement for all individual, family, and small group insurance policies in 23 states.
- The majority of insurers require a BMI of at least 40 (or 35 with co-morbidities) for patients to qualify for bariatric surgery coverage.
- Other typical criteria to demonstrate the medical necessity of bariatric surgery include past attempts at weight loss, passing a psychological evaluation, the cessation of smoking, and no evidence of substance abuse.
Does Insurance Cover Bariatric Surgery?
Bariatric surgery can be an expensive procedure, often costing tens of thousands of dollars. In the U.S., many insurance plans cover bariatric surgery when a patient meets certain criteria.
According to a recent survey of coverage criteria for bariatric surgery, 95% of companies have a clearly defined pre-authorization policy. They all covered Roux-en-Y bypass surgery, and most also covered laparoscopic adjustable gastric banding or sleeve gastrectomy.
The majority of insurers required BMIs of 40 and above, or 35 and above with a co-morbidity present, and a supervised medical weight management program (MWM) prior to the approval of bariatric surgery.
States Where Insurance is Required to Cover Bariatric Surgery
Under the Affordable Care Act’s (ACA) Essential Health Benefits (EHB) Benchmark Plans, 23 states require that all individual, family, and small group insurance plans cover bariatric surgery. Those states are:
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Rhode Island
- South Dakota
- West Virginia
Also under the ACA, in the following three states, bariatric surgery coverage must be offered in at least some (but not all) policies:
- Georgia, where a 1999 state law also mandates coverage for morbid obesity
- Indiana, where a 2000 state law also mandates coverage for morbid obesity
- Virginia, where a 2000 state law also mandates that coverage for morbid obesity must be offered in at least one plan by each state-regulated health insurer
Medicare and Medicaid Coverage of Bariatric Surgery
Both Medicare and Medicaid cover some bariatric procedures, including gastric bypass surgery and laparoscopic banding surgery, for patients who meet the criteria.
How to Get Insurance to Pay for Bariatric Surgery by Demonstrating Medical Necessity
Most insurance plans require that medical necessity be demonstrated before coverage is granted for weight-loss surgery. This means that in addition to your consultation with them, you’ll need to provide evidence that bariatric surgery is necessary for each patient. The exact criteria vary from one insurance provider to the next but typically include the following.
Age 18 or Older
Bariatric surgery is generally only available to patients who are 18 years or older. The majority of plans do not cover pediatric bariatric surgery.
Body Mass Index Above 40
Most insurance companies will require that patients have a body mass index (BMI) of 40 or above to be candidates for bariatric surgery.
Alternatively, patients with moderate obesity may be candidates for bariatric surgery if they have a BMI of at least 35 and there are co-morbidities present such as high blood pressure, type 2 diabetes, clinically significant obstructive sleep apnea, coronary heart disease, or hypertension.
Some insurance companies may require your patient to be moderately or morbidly obese for a particular duration of time before surgery is approved.
Past Attempted Weight Loss
In most cases, insurance companies require that your patient has made sufficient efforts to lose weight before they’ll approve coverage for bariatric surgery. This can include completing a medically supervised weight-loss plan developed by the insurance provider or making other efforts to lose weight as recommended by a doctor. Generally, insurers require the program or efforts to last from three to seven consecutive months.
If your patient has been unsuccessful in their weight-loss efforts after this period, they may then be considered a candidate for bariatric surgery. You will likely need to provide documentation of the attempts to lose weight, including dietary and exercise regimens, to gain insurance approval.
Most insurance companies will also require your patient to have a psychological evaluation before they approve them for bariatric surgery. This is to make sure that they have a realistic expectation of the results from the surgery and the information and support they need for long-term success after the surgery is complete.
The psychological evaluation will look at their:
- Reasons for seeking bariatric surgery
- Weight and diet history
- Current eating behaviors
- Understanding of the surgery and its associated lifestyle changes
- Social support and history
- Psychiatric history
In the video below, Dr. James Glynn talks more about what patients can expect from their psychological evaluation.
Quit Smoking and Avoid Substance Abuse
Finally, most insurance companies will require that your patient cease smoking and not display any evidence of substance abuse or have a recent history (within the past 5 years) of substance abuse before they will cover bariatric surgery.
Use Modern Tools to Help with Insurance Approvals and Billing
Knowing and consistently applying the latest criteria from each insurance company is critical to ensuring your patients are able to be approved for surgery.. You can further simplify the insurance process for you and your patients by using the latest tools to help tailor the evaluation requirements and streamline the pre-authorization process.
Find out how Wellbe’s personalized care automation can help you streamline insurance approvals and billing, as well as hundreds of other non-medical administrative tasks.