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Gastric Sleeve Insurance

Gastric Sleeve Insurance

For weight loss surgery, health insurance plays a pivotal role in many patients' ability to have life-saving weight loss surgery.  Many barriers must be overcome before surgery is approved by most insurance companies.

The most common misconception about weight loss surgery is that even if you are morbidly obese, it does not automatically mean you will receive weight loss surgery approval.

The most common guidelines that insurance companies must meet include:

  • BMI of 40 or higher
  • BMI between 35 and 40 with another condition
  • Type 2 diabetes
  • High Blood Pressure
  • Sleep Apnea
  • Unsuccessful previous dieting and exercising attempt

The importance of weight loss surgery is critical for Americans' health due to the rapidly increasing obesity epidemic.  According to the Centers for Disease Control and Prevention research, obesity has doubled within the past 30 years.

Another startling statistic is that almost 40% of all American adults are obese.  This proves that obesity is a national problem and that weight loss surgery is a medical necessity and can save lives.

Income flexibility limitations are a real concern for bariatric patients. 

Gastric Sleeve Insurance Coverage

To receive gastric sleeve insurance coverage, your chances of receiving coverage by your health insurance greatly increase with the following obesity-related health issues.

The following health issues that improve your chances for coverage include:

  • Arthritis
  • Asthma or another Breathing Disorder
  • High Blood Pressure
  • Sleep Apnea
  • Acid Reflux
  • High Cholesterol

Alongside having the previously listed health conditions, your eligibility for health insurance coverage increases when you have an elevated BMI.  If your BMI is higher than 40 or at least 35 with another obesity-related health condition, then insurance approval greatly increases.

Bariatric surgery is the strongest treatment option for patients because it greatly improves your overall quality and life expectancy.

Be prepared for excessive paperwork to obtain insurance coverage.

Gastric Sleeve Insurance Requirements

Most health insurance companies require many appointments to determine your overall health condition.

These appointments normally include a full medical analysis with a pre-authorization request.

Your insurance will also require documented previously supervised weight-loss attempts.  Most insurance companies do not cover weight loss programs by themselves.  Because of this, using Weight Watchers or Jenny Craig will not count as a previous attempt.

For pre-authorization approval for your surgery, you will receive specific insurance company demands for surgery coverage.  You should expect many appointments and paperwork throughout this process.

Your bariatric health care team will work with you to make sure you receive insurance approval for surgery.  All of the pre-authorization guidelines are procedures in place to reduce any deemed unnecessary surgeries.

Mental health support is an important aspect of weight loss surgery preparation.

Best Health Insurance for Gastric Sleeve

Medicare does cover weight loss surgeries when deemed medically necessary for the severely obese.

Both laparoscopic  vertical sleeve gastrectomy and gastric bypass surgery are covered through Medicare.  For surgery authorization, you need to be approved through a variety of health evaluations and assessments.

Medicare typically takes five months to process and approve or deny your bariatric surgery request.

Gastric sleeve insurance coverage varies depending upon which insurance coverage you have available.

Aetna and CiGNA are common health insurance companies to consider for your surgery.

Aetna insurance has plans that cover bariatric surgery if you have been morbidly obese for a minimum of two years.  This means that your BMI should be higher than 40 or with a comorbidity condition directly related to your morbid obesity.

Most Aetna HMO group plans do not include weight loss surgery unless through direct approval.  These are important aspects of insurance policies to consider.

CIGNA is another health insurance that does provide bariatric surgery coverage under some group medical plans.  It fully depends upon each client if they choose to elect bariatric surgery coverage.

Exercise is important to harness before surgery to develop great new lifestyle habits. 

Detailed Health Insurance Coverage for Gastric Sleeve

For gastric sleeve surgery insurance coverage, you are required to receive behavioral counseling, obesity, and nutritional screen appointments as part of their standard surgery approval process.

For insurance CIGNA coverage, your gastric sleeve surgery must be medically necessary with the following requirements:

  • At least 18 years old
  • BMI of more than 40 for 2 years or a BMI between 35 and 40 with one obesity-related comorbidity
  • Type 2 Diabetes
  • High Blood Pressure
  • High Cholesterol
  • Sleep Apnea
  • Participated in a weight loss program within the past 2 years unsuccessfully
  • Successful health evaluations
  • Bariatric surgeon
  • Mental health assessment
  • Dietician health assessment
Meal preparation is a healthy aspect of weight loss and is a great skill to learn.

Gastric Sleeve Insurance Approval

Overall, health insurance companies choose to approve bariatric surgery because bariatric surgery leads to lowering your overall health care costs substantially.

Bariatric surgery also improves your ability to increase your work productivity which improves your effectiveness as an employee.  These two reasons are important considerations most insurance companies use for approving surgery.

For the most part, insurance companies cover bariatric surgery. You can determine your eligibility by checking your insurance policy before choosing to schedule your weight loss surgery.

You should check to see if you need pre-authorization for insurance coverage and if obesity surgery is included in your policy.

Gastric Sleeve Insurance Denial

If your health insurance denied your request for bariatric surgery, then you still have options for financing your weight loss surgery.  You can begin an appeals process through your insurance company to improve your case for surgery coverage.

If your appeal is denied, you should be aware that the cost of weight loss surgery is high.

The national average cost for bariatric surgery is between $17,000 and $26,000.  On the positive side, research shows that having weight loss surgery helps eliminate obesity-related health care costs in the long term. Therefore surgery is the best financial option overall.

To avoid paying the high cost of this surgery, your appeals process should include more detailed documentation of your health condition to make your surgery deemed medically necessary.

Most appeals must be filed within 60 days of the initial denial.  You can begin this process with a phone call and then move towards a written appeal.

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Kelsey Renae Schulze

Author

Kelsey is a post-op bariatric patient who had sleeve surgery in 2018. She is a writer, focusing on a variety of topics given her background in legal studies and criminal justice.