Insurance Information

Will my insurance plan cover this surgery?
Increasingly, insurance companies are beginning to recognize that obesity surgery is much more than a “cosmetic” procedure, and they are covering it more now than ever.

Generally, the first step in pursuing this type of surgery is to see your primary care physician and ask for a referral to a WLS surgeon. The surgeon’s office will request authorization for surgery from the insurance company. From there, it’s important to keep the lines of communication open, both with your doctors, and with the insurance company.

Note the exact name and phone extension of the people you speak with at your surgeon’s office and your insurance company.  Being able to ask for the same individual on subsequent calls should help make the process a bit easier for you.

If you are denied initially, do not hesitate to appeal! This surgery is often approved on appeal. Even if your policy has an exclusion against WLS, you may be able to get coverage by proving that the procedure is “medically necessary” to alleviate co-morbidities (health problems that are exacerbated by your weight, and which would be improved by losing weight -- such as hypertension, diabetes, degenerative joint disease, asthma, sleep apnea -- just to name a few).

The patient must contact their insurance to conferm that Bariatric Surgery is a covered benefit on their policy.

Insurance Requirements for Gastric Bypass Surgery

Aetna- Age 18-65. Must have been 100 lbs. overweight for the past 5 years. BMI of greater than 40 with secondary health condition or BMI of greater than 35 with primary health condition ( Coronary Heart Disease, Type 2 Diabetes Mellitus, Obstructive Sleep Apnea, Hypertension). Partcipation in physician or nutrionist supervised nutrition and exercise program of at least 6 months duration within the past 2 years. This documentation must be in primary care physicians progress notes; aletter is not sufficient.

BC/BS of Mi- 18-60 years of age (If over 60, primary care physician must document that the member's physiological age and comorbid condition result is a positive risk/benefit ratio) BMI of greater than 40 with secondary health condition or greater than 35  with primary health condition such as degenrative joint disease, hypertension, hyperlipidermia, heart disease, Type 2 diabetes Mellitus or sleep apnea. Documentation of physician-supervised weight loss program for a minimum of 12 consecutive months prior to the recommendation for surgery. Documentation should include periodic weights, dietary therapy, and physical exercise, as well as behavior therapy, counseling and pharmacotherapy, as indicated. Documentation that the primary physician and the patient have a documented good understanding of the risks involved and reasonable expectations that the patient will comply with all post surgical requirements.

Blue Care Network/Blue Choice - Age 18-65 BMI greater than 40. Primary health condition diagnosed and treated by physician (Hypertension, diabetes Mellitus, Obstructive Sleep Apnes, Heart Disease, Hypercholesterolemia, Gastro Esophageal reflux Disease, Degenrative Joint Disease or Degenrative Disc Disease). Participation in physician supervised weight loss program for 1 consecutive year within the past 3 years with monthly visits including weigh-ins, behavior modification, counseling, medication (if appropriate), nutritionist services and exercise. A physician summary letter is not sufficient documentation for diet history.

Cigna - Age 18 - 60. BMI greater than 40 for at least 1 year with secondary health condition or greater than 35 with primary health condition ( Coronary Heart Disease, Type 2 Diabetes Mellitus, Obstructive Sleep Apnea, Hypertension). Participation in one recent 6-month weight loss program that is directed by a physician who does not perform weight loss surgery, icluding wegh-ins, dietary therapy, increased physical activity, and behavioral therapy to reinforce the diet and physical activity. A program such as Weight Watchers, or weight loss medication alone is not considered suffcient documentation. A physician summary letter is not sufficient documentation for diet history.

Connect Care - Age 18-65 BMI greater than 40 or 100 lbs. overweight. Letter from primary care physician recommending gastric bypass surgery, ruling out organic illness and stating there are no contra-indications to the surgery. Participiation in a 6 month physician supervised diet with monthly weigh-ins. Must have a primary health condition (Hypertension, diabetes Mellitus, Obstructive Sleep Apnes, Heart Disease, Hypercholesterolemia, Gastro Esophageal reflux Disease, Degenrative Joint Disease or Degenrative Disc Disease).

Health Plus - Age 18 -  65, BMI greater than 40. Primary health condition

M Care - Age 18 -  65, BMI greater than 35 with 2 primary health conditions (Hypertension, Diabetes mellitus, Obstructive Sleep Apnea, Heart Disease, Hyperlipidemia). Documentation of a physician-supervised weight loss approach for 12 months including periodic weights, dietary therapy, exercise, behavioral therapy, counseling and pharmactherapy, if applicable. Documentation must include regular attendance (greater than 80%) and at least 5% excess body weight loss during treatment. Initial weight loss with regain without participation in a maintenance program is not considered compliance. medical evaluation has ruled out any underlying treatable cause for obesity. Documentation of 100 lbs overweight for the last 5 years.

Medicaid - Age 18 - 65, (some policies vary on age limit). BMI greater than 40. Must have 2 of the following primary health conditions that are uncontrolled with medications: Hypertension, Diabetes, Heart Disease, and Sleep Apnea. Letter of support from the primary care physician which includes health conditions, past supervised dieting attempts, current medications, and clear recommendation for weight loss surgery. Authorized referral for Medicaid HMO participants. last 5 years of medical records. Copy of front and back of the current medical card(s)

Medicare - Age 18 - 65. BMI greater than 40. Must have 2 of the following primary health conditions that are uncontrolled with medications: Hypertension, Diabetes, Heart Disease, and Sleep Apnea. Letter of support from the primary care physician which includes health conditions, past supervised dieting attempts, current medications, and clear recommendation for weight loss surgery. Last 5 years of medical records. Copy of front and back of the current insurance card(s).

Messa - Age 18 - 65. At least 100 lbs overweight. Must have secondary health condition.