Will my health insurance company pay for weight-loss surgery?

If you’ve spent years trying traditional weight-loss methods that rely on diet and exercise but you still can’t keep the weight off, it may be worth considering bariatric surgery options such as gastric band or gastric bypass.

Such weight-loss procedures have been growing in popularity. In 2009, about 220,000 Americans underwent bariatric surgery, compared with 16,000 a year in the early 1990s.

Studies cited by the American Society for Metabolic and Bariatric Surgery have shown patients may lose 30 percent to 50 percent of their excess weight six months after surgery and 77 percent of their excess weight as early as one year after surgery.

Furthermore, the group says, gastric band and gastric bypass surgeries have been shown to eliminate Type 2 diabetes in more than three-fourths of patients and cut the risk of coronary heart disease by half. Even better, the group claims these surgical procedures can cut the risk of early death by as much as 40 percent.

weight_loss_surgeryWeight-loss procedures often are covered by health insurance, but patients must meet strict criteria, demonstrating that other efforts have failed consistently.

Not always the solution

However, these procedures aren't for everyone. If you want to lose 30 pounds or so and you don’t have any obesity-related illnesses, the risks of bariatric surgery may outweigh the benefits. “Patients should never be in a hurry to have surgery if they don't have” co-existing conditions, such as Type 2 diabetes or heart disease, according to Dr. Carson Liu, a bariatric surgeon in Southern California.

Liu says some patients may be better able to tolerate a certain amount of extra weight without risking poor health, based on their physical and genetic makeup. A person’s body-mass index doesn’t tell the full story. For instance, “bodybuilders who are in shape have very high BMIs,” he says.

And even for those who are obese, doctors are reluctant to operate unless their patients have demonstrated they're willing to change their eating and lifestyle habits.

The costs of gastric bypass and other bariatric surgeries can be substantial. If the operation isn’t covered by your health insurance, it can cost as much as $26,000. Complications leading to further medical expenses are common. In a 2009 study, 40 percent of 82 patients who’d had gastric banding done between 1994 and 1997 had experienced serious complications; 60 percent needed more surgery.

Will you be covered?

If you have a significant amount of weight to lose and are committed to a healthy lifestyle, the first step is to consult with a bariatric surgeon. This specialist can tell you whether you’re a good candidate for weight-loss surgery and can go review your options.

Once you’ve determined a potential treatment plan, you’ll need to negotiate with your insurer for coverage of the surgery. Several insurers, including Blue Cross, CIGNA and Medicare, will pay part or all of the surgical cost in cases deemed "medically necessary."

“About 90 percent of the insurance providers we work with will have bariatric coverage,” says Lindsay Querubin, who handles insurance claims for Liu’s office. However, “every once in awhile, the surgery will be listed as an exclusion, or the patient’s obesity will be treated as a pre-existing condition that’s not eligible for coverage,” she says.

When is the procedure medically necessary?

Insurers that offer coverage for weight-loss surgery have guidelines for patient coverage. Details of some plans are available at SkinnyWishes.com.

Under CIGNA’s rules, a patient must be at least 18 years old and have a body mass index of at least 40, or must have a BMI of at least 35 coupled with issues such as diabetes or high blood pressure. “Many benefit plans specifically exclude bariatric surgery, but this coverage policy is the standard for those plans that do cover the surgery,” CIGNA spokesman Mark Slitt says of his company's coverage.

Stating your case

Even if a patient meets the insurer’s criteria, he still may need to state his case to the insurance company.

Most insurance companies will require a letter of medical necessity from your surgeon and your primary physician. The letter should include your weight history and BMI, your obesity-related health conditions and treatments, and a history of previous diet and exercise efforts.

Under CIGNA’s rules, for instance, a patient must show proof that he has participated in a doctor-supervised weight-loss program for at least six months. The policyholder also must seek approval for surgery from a nutritional consultant and a mental health care provider.

Lori Ruff, a social media consultant from Minnesota who underwent gastric bypass surgery in 2004, says that in the months leading up to the surgery, her doctor mandated daily exercise. “He said if I missed a day at the Y, I should feel like my day was not complete,” she recalls.

With her doctor’s approval, she received full coverage for the surgery, a counseling session and two visits to a dietitian.

Before the surgery, Ruff’s BMI was 55; today, it is 28. “It has changed my life and certainly extended it by a considerable margin,” she says.

What if you’re not covered?

A 2008 Harris Interactive survey found that one-fourth of patients considering weight-loss surgery were denied coverage three times before getting approval.

If your insurer does cover bariatric surgery but won’t approve your proposed weight-loss surgery, you may be able to file an appeal based on additional information, using the services of an insurance advocate if necessary. If you’re planning on buying a Lap-Band -- a device that restricts the size of your stomach -- the product manufacturer can help negotiate reimbursement from insurers.

If you know that you don’t meet your insurer’s criteria for coverage or your provider doesn't cover it all, it may be necessary to pay for the surgery out of your pocket. Most clinics, including Liu’s, offer cash discounts and long-term financing, according to Querubin.

Coverage becoming more common

As the surgeries become safer and more common, patients may run into fewer roadblocks with getting coverage for bariatric procedures. The Dallas Morning News reported Aetna approved 40 percent more weight-loss operations each year between 2006 and 2008.

Bariatric surgery coverage is a low-risk proposition for insurers. A September 2011 study in The American Journal of Managed Care found that insurers recovered their costs for the surgery within two to four years, as patients were less likely to suffer from chronic illnesses related to obesity. More than 15 million Americans are considered morbidly obese.

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