Employers who offer coverage vary by state and insurance provider. If you’re thinking about bariatric surgery in the near future, start looking at your insurance benefits today. Some insurance plans cover all or part of the cost.  By calling 1-866-REALIZE, we can help you check to see if your employer provides insurance coverage options. You can also use our guide “Advocating Bariatric Surgery Insurance Coverage at Your Workplace” as you begin the process of determining insurance coverage.

For more assistance, find a bariatric surgeon and program using the Surgeon Locator.

Also, Learn How To...

ADVOCATE FOR BARIATRIC SURGERY COVERAGE

FIND ALTERNATIVE FINANCING OPTIONS FOR BARIATRIC SURGERY

Since every insurance policy is unique, it's important that you thoroughly understand your certificate of coverage to know exactly what is and isn't covered through your plan.

To qualify for insurance coverage, many insurers require patients to have a history of medically supervised weight loss efforts. Insurance companies may consider the following efforts when evaluating the appropriateness of bariatric surgery including laparoscopic gastric banding:

Keeping track of every visit you make to a healthcare professional for obesity-related issues or visits to supervised weight loss programs.

Making note of other weight loss attempts made through diet centers and fitness club memberships.

If your bariatric surgeon recommends bariatric surgery, he or she will be required or can assist with preparing a letter to obtain preauthorization from your insurance company. The goal of this letter is to establish the medical necessity of bariatric surgery and gain approval for the procedure. The following information is generally included in the preauthorization letter:

1. Your height, weight, and Body Mass Index, and any documentation you might have as to how long you have been overweight.
2. Simply describing your condition as morbid obesity is not enough. A full description of all your obesity-related health conditions, including records of treatment, a history of medications taken, and documentation of how these conditions affect your everyday life, is necessary.
3. A detailed report of how your excess weight affects daily activities, such as walking, tying your shoes, or maintaining personal hygiene.
4. A detailed history of the results of your dieting efforts, including medically and non-medically supervised programs, medical records, and records you may have kept of payments to and meetings you’ve attended with commercial weight loss programs. Visit our Helpful Tools for a helpful tracking sheet template.
5. A history of exercise programs, including receipts for gym memberships.
6. Confirmation of your mental health. This should indicate that you are able to understand, tolerate and comply with all phase of care and that you are committed to long term follow up requirements. This includes documentation that you have completed a preoperative mental health assessment and that your treatment plan includes counseling to support any psychological issues.
7. Ask your doctor to include clinical information about the effectiveness of bariatric surgery, particularly the control or loss of obesity-related health conditions.

Normally, your insurance provider will respond to your request within 30 days. You should schedule a follow-up if you have not heard from your insurance company in that amount of time.

The health insurance coverage information contained in this section is provided for information purposes only and represents no statement, promise or guarantee by Ethicon Endo-Surgery, Inc. concerning levels of coverage, reimbursement, payments or charge.

If the insurance company turns down your request for bariatric surgery, you may be able to appeal the decision. Many people do not take advantage of the appeals process or know of the laws that govern insurance companies in their state.

Work with Your Bariatric Program

Assistance is key. It is critical that you work with your bariatric program to determine the correct approach to appealing a denial. Your program is there to assist you and to help you adhere to your policy’s requirements.

Tip

Write a description of how morbid obesity decreases the quality of your life. Be sure to include details such as difficulty walking, socializing, or maintaining personal hygiene. This documentation can be useful for your bariatric program and health insurance company.

Possible Options After Appeals

Even if you exhaust the appeals options, you still may have options:

Independent Review Board

Many states are required to have an independent, external board to evaluate the validity of denied coverage. This option is available to people in more than 40 states.

To look at your state’s website for filing instructions, click on that state. You may also locate a phone number to your state’s insurance commission in your phone book under government services. You can also ask your insurance company, employer benefits department or bariatric surgery program coordinator, if requesting an independent review of your case is an option. In states where an independent review is required, decisions usually are issued within 60 days.

Arbitration

As an alternative to a lawsuit, some health plans require or offer an option of seeking a coverage decision using a neutral third party. Arbitration occurs when an opinion or an evidence-based decision is made by an unbiased person. Instead of going to court, the parties dispute the case in front of an arbitrator that the parties have agreed on based on his or her experience and expertise in the field. This procedure is often less costly and less time-consuming than going through the court system. 

It is important to remember that arbitration might not always be an option or a better way of disputing a denied appeal. It is recommended to contact your plan to verify the options available to you.

Litigation

When a lawsuit is filed and brought before a court, it is called litigation.  This formal legal action is usually taken in the event all other options for obtaining coverage for your surgery have been exhausted. This option is expensive and time consuming. You can consult with your bariatric surgery program coordinator to identify local legal counsel in the event you feel legal action is required to gain access to bariatric surgery.

State Insurance Departments and Phone Numbers

Click on state and phone number to go to the state’s insurance department webpage

If your insurance policy does not cover bariatric surgery, you may want to discuss alternative financing options with your bariatric program.

For more assistance, find a bariatric surgeon and program using the Surgeon Locator.