For a growing number of patients, weight-loss surgery may 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 an average cost of between $15,000 and $36,000, insurance coverage is a important consideration for most 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 learn which states require insurance plans to cover bariatric surgery and typical insurance criteria for bariatric surgery coverage.
- most insurances cover bariatric surgery. bariatric surgery coverage is a requirement for all individual, family, and small group insurance policies in 23 states.
- Most insurers require a BMI of at least 40 (or 35 with comorbidities) for patients to qualify for bariatric surgery coverage.
- Other typical criteria for demonstrating medical necessity for bariatric surgery include prior weight loss attempts, passing a psychological evaluation, smoking cessation, 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 usa In the US, 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 prior authorization policy. all covered en and roux bypass surgery, and most also covered laparoscopic adjustable gastric banding or sleeve gastrectomy.
Most insurers required a bmis of 40 and above, or 35 and above with a present comorbidity, and a medically supervised weight management (mwm) program prior to approval of bariatric surgery.
states where insurance is required to cover bariatric surgery
Under the Affordable Care Act (ACA) Essential Health Benefits (EHB) Benchmark Plans, 23 states require all individual, family, and small group insurance plans to cover bariatric surgery. those states are:
- new hampshire
- new jersey
- new mexico
- new york
- north carolina
- dakota del north
- 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 requires morbid obesity coverage
- indiana, where a 2000 state law also requires morbid obesity coverage
- virginia, where a 2000 state law also requires every state-regulated health insurer to offer coverage for morbid obesity in at least one plan
Medicare and Medicaid Coverage of Bariatric Surgery
Medicare and Medicaid both cover some bariatric procedures, including gastric bypass surgery and laparoscopic band surgery, for patients who meet the criteria.
how to get insurance to pay for bariatric surgery by proving medical necessity
Most insurance plans require proof of medical necessity before weight loss surgery will be covered. this means that in addition to your consultation with them, you will need to provide evidence that bariatric surgery is necessary for each patient. the exact criteria vary from one insurance provider to another, but generally include the following.
18 years or older
Bariatric surgery is generally only available to patients over the age of 18. most plans do not cover pediatric bariatric surgery.
body mass index greater than 40
Most insurance companies will require patients to have a body mass index (BMI) of 40 or greater to be candidates for bariatric surgery.
Alternatively, moderately obese patients may be candidates for bariatric surgery if they have a BMI of at least 35 and comorbidities are 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.
previous weight loss attempts
In most cases, insurance companies require that your patient has made sufficient efforts to lose weight before approving coverage for bariatric surgery. this may include completing a medically supervised weight loss plan developed by the insurance provider or undertaking other weight loss efforts as recommended by a physician. Insurers generally require that the program or arrangements last three to seven consecutive months.
If your patient has been unsuccessful in their weight loss efforts after this period, then they may be considered a candidate for bariatric surgery. You will likely need to provide documentation of weight loss attempts, including dietary and exercise regimens, to obtain insurance approval.
Most insurance companies will also require your patient to undergo a psychological evaluation before approving you for bariatric surgery. this is to make sure they have a realistic expectation of the results of the surgery and the information and support they need for long-term success after the surgery is complete.
The psychological evaluation will look at your:
- reasons to seek bariatric surgery
- weight and diet history
- current eating behaviors
- understanding of surgery and lifestyle changes associated living conditions
- social support and history
- psychiatric history
in the next video, 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 your patient to stop smoking and not show any evidence of substance abuse or have a recent history (within the last 5 years) of substance abuse before they will cover the surgery bariatric.
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 can be approved for surgery. You can further simplify the insurance process for you and your patients by using the latest tools to help customize screening requirements and streamline the prior authorization process.
Discover how wellbe’s personalized care automation can help you streamline insurance billing and approvals, as well as hundreds of other tasks non-medical administrative