Is Weight Loss Surgery Covered by Insurance?
The issue of being overweight or what is commonly known as obesity has over the past few years become a real problem in the United States. Research shows that close to 30% of the American adults’ population is obese, with the worst-case scenario in Arkansas, where 36% of the adult population is believed to be obese. Since most people know the risks of being obese, they are slowly turning to weight loss surgeries as an alternative. However, you should first exhaust all other weight loss practices such as physical workout and dieting before thinking of bariatric surgeries. This is because, on top of the side effects that are associated with the procedures, most of them are expensive. Although most insurance providers in the majority of the states cover weight loss surgeries, some do not. Even those that do cover, they have several requirements that must be met before they agree to cover your surgery.
Requirements for Coverage
Most insurance providers demand that you first meet some requirements for them to cover the surgery. You must provide documented proof from your surgeon, showing that the surgery is indeed necessary, failure to which it causes serious health risks. You must also present a documented proof from a nutritionist, stating that indeed you have been observing the necessary dietary habits before the surgery. Some insurers demand that you present to them a documented proof of appointment with a psychological counselor to ascertain that you are of sound mind before the surgery and that you understand the risks that come with the surgery.
Other insurance providers demand that you complete a 6-month physician-supervised dietary program. This program is aimed at telling you that you tried other weight loss methods such as dieting, and they failed, leaving you with no choice but weight loss surgery. All insurance providers demand that you have a BMI of 35 and above and are experiencing some conditions like high blood pressure and type 2 diabetes. You must not have any record of smoking and substance abuse, some months before the surgery.
Reasons for Denial
Failure to meet the above requirements leads to an automatic denial of your request to be covered for the surgery. Your insurer may also decline your surgery coverage request if they realize that you colluded with the surgeon to have the documented proof doctored in your favor. It may sound hard for the insurer to ascertain this foul play, but they do; they have investigators who are very good at their work. However, the main reason for denial is if you entered into a contract that specifically does not cover bariatric surgeries. Therefore, before you start paying premiums for a particular health plan, ensure that you first understand the provisions in the contract form. This will save you disappointments and surprises in the future.
What Next After Denial?
If your surgery coverage request is denied, do not panic, there is a chance to appeal the decision. You can demand the insurance to present to you with details of why the request was declined. This plays an important role since a mistake may have occurred and led to the request being declined, so this gives a chance to crosscheck. Even as you do this, you should first ensure that you fully understand the specifics of the policy, it could be that the policy does not cover the surgery after all. Also, ensure that as you file an appeal, you have met all the requirements demanded by the insurer. If the request is still denied and you still feel the decision was unwarranted, you can file a claim with the insurance commissioner for your state.
If all these fail, then you have no choice but to pay for the surgery form your pocket. Most hospitals require that you pay for the surgery in full, before they start of the procedure. If you cannot afford to pay, most surgeons have financial plans where you pay on installments.
If you have been struggling with the problem of obesity and have been contemplating weight loss surgery for some time now, you should enter into a health insurance plan that covers these types of surgeries. Ensure that you read and understand all the provisions of the policy before you sign the contract form. If you are in a state that demands the insurance providers to cover the surgeries, then you are good to go. However, it is always good to confirm to avoid surprises and disappointments.
Dr. Saniea F. Majid, MD, FACS, FASMBS, is our founder, director, and award-winning surgeon with more than 10 years of experience treating patients. She is the President of the New Jersey state chapter of ASMBS, a member of the Board of Directors at New Jersey Doctor-Patient Alliance, and Chair of the Post Operative Weight Recurrence Task Force (POWER). Dr. Majid has devoted her life to helping people like you lose weight and transform their lives and not only started and directed the Metabolic and Bariatric Center at Saint Michaels Medical Center but also achieved the National Center of Excellence. Dr. Majid is one of only three bariatric doctors and surgeons featured in the 2023 Healthy Living magazine published by NJ Top Docs. She is also a regular guest speaker for the American Society for Metabolic and Bariatric Surgery (ASMBS) where she trains bariatric surgeons on the latest methods and techniques.