You’ve tried everything to lose weight, but nothing seems to work. Obesity has led to medical conditions that you never anticipated, such as type 2 diabetes and high blood pressure. You want to make changes but don’t know how. You think weight loss surgery might be the right choice for you.
Undergoing any medical procedure in the US today introduces the question of payment. While some patients have insurance through a job or family plan to cover healthcare costs, not all medical plans account for the surgical treatment of obesity. Even if your plan does cover weight loss surgery, there is no guarantee that your specific procedure will be approved.
Weight loss surgery, considered by many providers to be a non-essential procedure despite studies that indicate major preventative health benefits, is not included in all plans. Depending on the procedure and your location, weight loss surgery can cost up to $25,000. Most people seeking to improve their health through surgical means are not able to come up with that amount of money up front.
According to the Center for Disease Control and Prevention, “Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death.” Why, then, are more insurance companies not covering a surgery that can prevent, treat, and often, eliminate, these chronic – and expensive – conditions? More importantly, how can you get your surgery covered?
Be your own attorney
Think of applying for insurance coverage as building a case in favor of your desired outcome in court. You will need exhibits (documentation) to prove why you need the surgery. You should have expert testimony from your doctor stating why this procedure is medically recommended. You should be able to support your claim by demonstrating failed weight loss attempts. Preparing your application takes persistence and a thorough approach that leaves no stone for your insurer to unturn.
Dollars and sense
Weight loss surgery is a financial, physical and emotional investment that tends to cost more in urban areas like Boston, New York, and other cities along the Eastern Seaboard. This increase is due to high overhead in metropolitan areas and a higher demand for surgeons due to population density. You may want to consider traveling out of state for your surgery if your local offerings are not cost effective.
The cost of surgical procedures for weight loss include anesthesia, hospital facility fee and surgeon’s fee, dietary and fitness followup, nutritional supplements, and often behavior modification therapy to help patients overcome destructive eating habits post-op. Depending on how much weight they lose, patients may pursue cosmetic procedures, such as breast lifts or abdominoplasties, to lift sagging areas and remove excess skin. Be sure to consider what supportive measures you may want to take after weight loss surgery, and factor their costs into your plans.
Does my insurance cover weight loss surgery?
Insurance coverage for weight loss surgery varies by state and by insurance provider. According to Insure.com, nearly 25 percent of patients considering bariatric surgery are denied coverage three times before their request is approved, which, according to the American Society for Metabolic & Bariatric Surgery (ASMBS), is one of two reasons patients who need bariatric surgery do not receive it, second to unattainable prerequisites. These patients are denied coverage even with they have doctor recommendations and coverage options included in their plans.
While individual plans are unlikely to cover your surgery, group health plans provide more flexibility and are worth pitching to, particularly if you meet the BMI requirement for obesity and have a recommendation from your primary care physician. In this case, your employer must select bariatric surgery as an option in order for you to be covered.
Currently, six states mandate that group health plans cover treatment for morbid obesity: Georgia, Illinois, Indiana, Maryland, Virginia and New Hampshire. Even in these states, group insurance that is self-funded by your employer will not cover the cost of surgery, so be sure to inquire about how your company funds its health plan.
United, Blue Cross Blue Shield, Aetna
These three companies include provisions for weight loss surgery in their fine print or in certain regions, making them your go-to providers. Instead of wasting your time applying for coverage from providers that say they don’t fund weight loss surgery, consider which of the below companies’ criteria you meet and can prove.
United Healthcare: Although United’s Summary Plan Descriptions and Certificates of Coverage exclude weight loss surgery coverage, many of their plans do in fact cover it, particularly if you live in a state that makes this type of coverage mandatory. Where applicable, their requirements include:
- Body Mass Index greater than 40 (Class III Obesity)
- Body Mass Index greater than 35 (Class II Obesity) with at least one of the following co-morbid conditions:
– Type 2 diabetes
-Cardiovascular disease (hypertension, stroke, angina)
-Life-threatening cardiopulmonary conditions or severe sleep apnea
Specific surgeries covered include:
- Gastric bypass
- Lap adjustable gastric bands (lap band surgery)
- Gastric sleeve procedure (laproscopic sleeve gastrectomy)
- Vertical banded gastroplasty
- Biliopancreatic bypass
- Duodenal switch
Three of these procedures, gastric bypass, lap gastric bands, and gastric sleeve, are covered in adolescents.
Blue Cross Blue Shield: Most plans in the BCBS network do cover weight loss surgeries. Their requirements here in Oklahoma include:
- A five-year history of medically documented obesity, including attempted diets, exercise, and weight loss programs.
- 6 months of medically-supervised, non-surgical attempts at weight reduction without success.
- Psychological evaluation
- Letter confirming willingness to comply with these regulations.
Other requirements may include:
- Body Mass Index of 35 or greater
- Nutritional evaluation
- Weight-related medical conditions if BMI is below 40
Aetna: Aetna’s group HMO and POS, as well as individual plans, do not cover surgical operations or procedures used to treat obesity. However, if your Aetna package does include coverage, you must provide the following information to apply for surgical funding:
- BMI of 40 or more OR BMI > 35 with comorbid coronary heart disease, type 2 diabetes, clinically significant sleep apnea, or medically refractory hypertension.
- Attempted weight loss without significant, long-term weight reduction.
- Proof of participation in a physician-supervised nutrition and exercise program or a multidisciplinary surgical preparatory program.
For added assistance, send a duplicate mailing of your appeal letter and documents to the insurance commissioner for your state. In addition, consider using a professional appealer who works specifically with patients whose weight loss surgery claims have been denied. Walter Lindstrom Jr. is one well-known national advocate offering such services. Don’t give up!
If surgery is tax deductible, why won’t my insurance cover it?
TurboTax states that weight loss surgery, as well as some diet programs, are tax deductible due to your projected decrease in health care costs down the line. According to Insure.com, “Mounting evidence shows that surgery for morbid obesity can be more cost-effective than treating the conditions resulting from obesity.” So why are more health care providers not looking to the future and investing in the health of their clients?
While the answer is complex, the heart of the matter is that insurance companies approach medical coverage from the perspective of culpability. In their eyes, gaining weight appears to be the result of your own actions and so the cost of losing weight should also fall on your shoulders. However, equating fat with fault is a simplistic view that does not serve the growing crop of obese people in the US, which currently equals more than one third of the population.
While waiting for insurance companies to change their tune, your best bet for getting your surgery covered by a provider that includes weight loss surgery in their plan is to remember the three D’s: documentation, documentation, and, oh yeah, documentation. Your application should make it clear that your obesity is not treatable using standard diet and exercise methods and is, beyond a shadow of a doubt, causing substantial, negative changes to your health and well-being.
If you know that weight loss surgery is for you, don’t give up. By building a strong case for your treatment with appropriate documentation, appealing if your initial application is turned down, and seeking a legal advocate, you can work toward achieving a healthier, happier you, funded by insurance.