Are you considering having weight loss surgery?

If you don’t know what to expect, meeting the requirements for bariatric surgery can feel overwhelming.  Taking the time to research surgical options for weight loss and what qualifies a person as a candidate for bariatric surgery can help you decide which option may be best for you.

Why Bariatric Surgery?

Bariatric surgery is an alternative tool for individuals who need to lose a significant amount of weight for whom diet and exercise alone have not worked or for those who are experiencing significant health issues related to obesity.

How Does Bariatric Surgery Work?

Bariatric surgery can be a useful tool to help with weight loss.  Additionally, the risk of medical problems associated with obesity is reduced as weight loss occurs, therefore improving health.

Most weight-loss surgeries are performed laparoscopically, which means they are minimally invasive. These procedures can help facilitate weight loss by restricting the amount of food the stomach can hold, causing malabsorption of nutrients, or a combination of both.

Types of Bariatric Surgery

The most common bariatric surgery procedures are sleeve gastrectomy (vertical sleeve gastrectomy, sleeve, VSG, gastric sleeve), gastric bypass (Roux-en-Y), biliopancreatic diversion with duodenal switch (DS), and adjustable gastric band (lap band).  Each type of bariatric surgery has advantages and disadvantages.  A consultation with a bariatric surgeon can help you learn specifics about each of the surgical options and help you decide which one will be of the most significant benefit to you.

• Sleeve Gastrectomy (VSG, Gastric Sleeve) involves removing approximately 80 percent of the stomach.  The remaining sleeve-shaped stomach pouch holds a considerably smaller amount of food than a healthy stomach.  This helps to reduce the amount of food that can be eaten, therefore decreasing caloric intake.  Additionally, VSG has an impact on gut hormones that influence factors such as blood sugar, hunger, and feelings of fullness (satiety).
• Gastric Bypass (Roux-en-Y) is a two-part procedure.  In this procedure, the surgeon creates a small pouch at the top of the stomach.  This small pouch is the only part of the stomach that receives food, which significantly restricts the amount that an individual can eat or drink at one time. The small intestine is then cut below the main stomach and connected to the new stomach pouch.  Food flows directly from the pouch to this part of the intestine.The central, more substantial part of the stomach continues to make digestive juices.  The portion of the stomach that is still attached to the main stomach is reattached farther down, allowing digestive juices to flow to the small intestine.Gastric bypass achieves weight loss by gastric restriction and forced malabsorption.
• Biliopancreatic diversion with duodenal switch (DS) is also a two-part procedure. In this procedure, the surgeon creates a sleeve gastrectomy as the first part of the operation. The second part is the so-called diversional part. It involves a small bowel bypass. The duodenum is cut and reconnected to the last portion of the small bowel, creating a decreased nutrient absorption state.
• Adjustable Gastric Band (Lap-Band) is a procedure that involves placing an inflatable band around the upper portion of the stomach, which creates a small stomach pouch above the band. The size of the stomach opening can be adjusted by filling the band with sterile saline.  This is accomplished by injecting the saline through a port placed under the skin.

Bariatric Surgery Insurance Requirements

Although some insurance companies cover the cost of bariatric surgery, that coverage is not always automatic.  Many companies have guidelines that must be met before pre-approval for surgery is given.  For some, the process of meeting requirements for bariatric surgery is not complicated.

Unfortunately, for others, the process may be frustrating and time-consuming.

Insurance companies consider factors such as age, weight, and body mass index (BMI).  Additionally, the presence of any comorbidities is an important factor.  Comorbidity is defined as the presence of two or more disorders occurring in an individual at the same time.

Most insurance companies use, at a minimum, the guidelines for bariatric surgery set forth by the National Institute of Health.

Those guidelines include:

• High risk for obesity-related morbidity or death
• BMI greater than 40, or BMI greater than 35 with co-morbidities, such as diabetes, high blood pressure, heart disease, or sleep apnea
• Failure to lose weight with non-surgical methods
• Willingness to comply with lifetime dietary requirements

Will Medicare Pay for Bariatric Surgery?

Medicare does cover some bariatric surgical procedures if the candidate for surgery meets conditions related to morbid obesity.

However, there is no “blanket coverage” for all weight-loss procedures.  The requirements for Medicare coverage for bariatric surgery include:

• Have a body-mass index (BMI) of 35 or more
• Have documented evidence of obesity for at the previous five years
• Have documented proof of participation in a medically supervised weight-loss program.
• Have at least one comorbidity related to obesity
• Present a letter of referral from your primary care provider recommending bariatric surgery
• Pass a psychological evaluation
• All treatable medical disease and/or conditions must have been ruled out as a possible cause of obesity

Blue Cross Blue Shield Bariatric Surgery Requirements

Some Blue Cross Blue Shield insurance policies cover weight loss surgery.  Because every policy is different, it’s essential to review your policy and speak with your insurance agent if you have any questions.

If your BC/BS policy does cover bariatric surgery, you must meet the following requirements:

• Must be between the ages of 18 and 60 years old
• Exceptions to the age requirement may be made for patients under the age of 18 years if a referral from the primary care provider is established.  For an exception to be made, there must be a dramatic risk for the patient’s health if surgery is not performed.  The letter must also contain information regarding the client’s mental status, which should reflect the patient is mentally/emotionally prepared for bariatric surgery.
• Have a BMI of over 40, or
• Have a BMI over 35 and have at least one comorbid condition such as: Obstructive sleep apnea, Type 2 diabetes, Hypertension (high blood pressure), or Coronary artery disease
• Provide written evidence that shows participation in one or more weight loss programs that have been unsuccessful.  

Blue Cross Blue Shield Federal Employees Program offers coverage for federal employees and does cover some bariatric surgeries.  Gastric bypass and lap-and procedures are covered.

Gastric Sleeve may or may not be covered, depending on individual circumstances.

What if My Insurance Company Doesn’t Want to Pay for Bariatric Surgery?

Significant research indicates that surgery for morbid obesity is more cost-effective than treating health conditions that may be the result of obesity, such as hypertension or heart disease.

Unfortunately, some health insurance companies may not pay for a bariatric procedure, even if you have a doctor’s recommendation.  That does not mean all hope is lost, though.

It’s always good to check your policy guidelines carefully and make sure your policy does not exclude weight loss surgery.

Even if your policy covers weight loss surgery, the claims process can still be lengthy.  If bariatric surgery is not exclusively excluded in your policy, but you are denied, file an appeal.  It is important to file your appeal as soon as possible after you are denied, as most insurance companies have a time limit on the amount of time during which an appeal can be filed.

Your insurance provider will likely require a full medical and psychological assessment and require that a pre-authorization request is submitted for approval.  Additionally, most insurance companies need physician-supervised weight-loss attempts (usually at the policy holder’s expense).  Medically supervised weight loss attempts do not include programs such as Jenny Craig or other services that provide pre-packaged meals.

When Insurance for Bariatric Surgery is Not an Option

When your insurance policy excludes bariatric surgery as a benefit, and if your appeal is denied, there are other options.  Some surgeons offer in-house financing.  Further, a secured or unsecured medical loan, a loan from family, or travel to a less expensive location for surgery are options.

Conclusion

As frustrating as the process may feel initially, it is essential to research different surgery options and alternative payment methods for any weight loss surgery.  Claim denials are not uncommon, but it is also not uncommon to have those decisions reversed on appeal.  Therefore, if having weight loss surgery is something you feel determined to do, weigh your options, and follow-through.

Talk to your insurance agent to see what requirements your company has.  Then make an appointment with your primary care provider and make sure that you have documented evidence of weight loss attempts.

Remember, bariatric surgery is a tool.  It can be a potent tool to help you achieve your weight loss goals and to help improve your overall health and well-being.