Health insurance provides coverage for many types of surgeries including those for weight loss or obesity. Weight-loss or bariatric surgery can include procedures such as the insertion of a lap-band or a performing a gastric bypass (See Resources.). Each type of surgery typically has various types of requirements to be met before insurance will cover the costs. This is because insurance companies need to be convinced that weight-loss surgery is medically necessary before approving coverage.
Getting Approval
Multiple steps are necessary to gain approval for weight-loss surgery. On step is to make sure the "certificate of coverage" for a health insurance policy is fully understood. The certificate will include all types of procedures that are covered by the insurer. Another step is to keep detailed records for each doctor's visit when the visit is related to obesity. A referral from a primary-care physician to a surgeon or specialist will also be needed to start the authorization process.
Authorization
The process for approval for a weight-loss procedure such as gastric bypass and lap-band surgery can be a lengthy process. The purpose or "medical necessity" for the surgery needs to be verified before an insurer will authorize the procedure. This can include diseases such as diabetes that are the result of being obese. A surgeon needs to send the insurer a letter of verification that lists the reasons why weight-loss surgery is necessary. This process is known as pre-authorization and is usually required for elective procedures.
Lap-Bands
A lap-band procedure or surgery is one of the more popular procedures for weight loss related to obesity. An insurance company may have specific requirements that need to be met before the procedure will be covered. This includes a history of obesity of five years or more, records of diets that are medically supervised and documentation of previous weight-loss attempts. A psychological exam also may be necessary.
Costs
The costs of weight loss surgery can vary depending on the procedure. Most gastric-bypass and lap-band surgeries can cost between $15,000 and $25,000. These costs typically include hospital fees, the fee for the surgeon, anesthesia during the surgery, fees for any lab tests or x-rays that are necessary and other types of miscellaneous fees. Many surgeons that perform weight-loss procedures may have information available for various financing and payment plans.
Appeals
If an insurer denies a pre-authorization for weight-loss surgery for obesity, an appeal can be made to the insurer. During this process, an individual will need to contest each reason stated by an insurer for denying coverage for the procedure. An insurance advocate or an attorney may be helpful when appealing a claim denial.
