Insurance for Gastric Bypass Surgery

Many people have insurance questions about coverage of gastric bypass surgery.

New! 12 page report on Health Insurance and Gastric Bypass Surgery.

Your health insurance helps you pay for your health care - but will it help you lose weight or overcome obesity? Being overweight causes a lot of medical problems, and that can be expensive. Does that mean treatment for obesity is covered by your health insurance?

Not necessarily, although coverage for gastric bypass surgery is becoming more common as the high cost of obesity is becoming apparent.

It may seem irrational to pay to treat the diseases caused by obesity, such as diabetes, high blood pressure, heart disease and some types of cancer - but not pay for weight loss treatment, drugs or gastric bypass surgery. In many cases, however, a diagnosis of obesity (and any treatment for this illness) is an "exclusion" of health insurance contracts. You can find out by reading your benefit booklet or contract.

I work for a health insurance company, and when I was a customer service representative I answered many questions about this issue. Callers were understandably frustrated when they found out they had to pay for this medical treatment themselves. The very large insurance company I work for has very few plans that cover weight loss surgery.

However, Mary McGowan, MD., who helped develop the bariatric surgery program at Catholic Medical Center in Manchester, New Hampshire, states that many insurance plans will pay for bariatric surgery if you give them enough evidence of medical necessity.

If your policy excludes all coverage for weight loss treatment, It doesn't mean you don't need the surgery, or that you can't have the surgery done. It only means that your policy might not cover it.

Health insurance and gastric bypass surgery

Health insurance companies are more than willing to sell any coverage that companies are willing to pay for - but the more services they cover, the more expensive it gets. Most employers have to make hard choices when they purchase their group policies.

One problem is that each state mandates many services that must be included in every policy, and each year the number of mandated services goes up. In my state, for instance, pregnancy must be covered in every policy, even if the members are over 50 years old. Our neighboring state mandates all alternative treatments such as chiropractic, naturopathic and massage, whether the group wants them or not. These services must be paid for before any other services can be added.

These legal mandates often take up the full amount of a small company's health insurance budget. Additional "riders," such as those that would cover obesity or smoking cessation, are simply out of their economic reach.

In order to give basic coverage to as many of their employees as possible, most companies have to limit the number of things they can include in the group policy. Obesity is almost always left out.

Gastric Bypass Surgery, which is used in the treatment of morbid obesity, can cost from $17,000 to $34,000, if there are no complications. Because complications are common, the full costs could actually be much higher. According to the NIDDK website from 10 to 20% of gastric bypass patients will have complications that require follow-up surgery

If you and your doctor are considering bariatric surgery, and your insurance does not cover the cost, you need to be sure you understand, and can afford, any potential complications.

How can you find out if you're covered for nutritional counseling, diet drugs or bariatric surgery?

One common way is to call your health insurance company and ask them. I strongly recommend that you actually read your benefit booklet before you make your first call to your insurance company. It pays to be informed. After all, the customer service representative who answers the phone may have been hired yesterday - with something this important, you'll want to be as prepared as possible, so you'll know what questions to ask, and whether or not you're getting the right (honest) answer.

The 800 number for your insurance company's customer service department should be on your ID card. If the treatment for obesity is covered, your doctor may still be required to submit a request for pre-authorization. The customer service representative you call will be able to help you find this information in your policy, and tell you if coverage is available, and how to find out if your qualified.

If your first call to your insurance company doesn't answer all your questions, or if the customer service representative's answers were too confusing, don't hesitate to call again. You will probably get a different representative, who may be able to explain things more clearly. However, if the contract says that obesity is an "exclusion of the contract", the representative can't change it.

If your benefit booklet is available online, it's usually easy to do a search (if the booklet is in the Acrobat Reader format.) Search for the words "obesity," "weight loss," and "exclusions." Read any paragraphs that pertain to these words. You may discover that your policy may exclude "self-help" programs for weight loss, but will allow gastric bypass surgery if you meet the specific criteria. (For common criteria for weight loss surgery, click here.)

If your insurance allows weight loss surgery if you meet their criteria:

If you discover that your policy may cover your surgery, you will then be asked to prove that you actually meet the criteria that they require. Before sending any documentation to the company, or asking your surgeon or physician to do so on your behalf, ask the insurance company for a printed copy of their medical policy on gastric bypass surgery. Many large companies have these policies available to the public on their websites, but the customer service department can also print a copy and mail it to you. Take this medical policy with you when you meet with your doctor, and ask if he or she believes that you are qualified, under the insurance company's guidelines. If you are, your provider will almost always be willing to write a letter that will help you get a preauthorization for the procedure.

If your insurance policy excludes weight loss treatments:

Your policy may state specifically that weight loss surgery and all it's complications are excluded from coverage. Even if your booklet says this, be sure to call the company anyway. You may be allowed file for a special exception on the basis of medical necessity. The outcome of the request will depend on the wording of the policy and any internal administrative rules and medical policies that have been developed by the insurance company. Some companies will not go outside the wording of the contract, and will not allow special exceptions.

If you are allowed to request a special exception, ask your customer service representative for the details about how to do it.

Your grievance and appeal rights:

If your policy will allow gastric bypass surgery, but they turn down your request because they do not believe you meet the criteria, you probably have the right to appeal their decision. Your grievance or appeal rights, if any, will be listed in your policy or benefit booklet, or you can call the company and ask them about it. They will probably mail forms to you and your doctor, and may give phone numbers to the appeal department. Your state's insurance commissioner may also give you advice. However, remember that your policy is a contract, and if the surgery is an exclusion of the contract, your appeal may not help you. Read your contract, and be sure to have realistic expectations. After all, if your group didn't pay for gastric bypass coverage, the insurance company has no moral obligation to give it to you for free, even if your doctor believes it to be medically necessary.

For the future:

If you and your union or fellow employees believe that obesity treatment would benefit a lot of people, you may be able to negotiate with your employer to have this service added to next year's policy. Unfortunately, with health costs rising all the time, many companies are struggling just to stay even with health care coverage - adding more benefits may be a very hard sell. You'll need to find the numbers to prove that weight loss treatment, even when it's expensive, will save the company money in the long run.

I know that several companies in my state are now experimenting by adding gastric bypass surgery coverage to their insurance contracts to see if this reduces the overall cost of medical care for their members. Obesity does affect the bottom line of many companies because of the increased illnesses and absenteeism. But many people still see this as a lifestyle choice, and are not willing to increase everyone's health care costs for the benefit of a few employees.

Jonni Good is the author of most of the original articles on this site. Jonni always looks for the easy way to solve common health problems, by working with human nature. Her books have helped hundreds of people lose weight, get fit, and regain their health - with less struggle. Please take a moment to visit her other sites:

Do You Gain Weight... Even when you eat less than your thinner friends? Learn why it happens, and how to use nutritious, satisfying food to break the metabolic pattern that causes some people to gain weight too easily.

Sugar Cravings and Addiction – Describes a simple program to help people break their addiction to sugar and fat. This book has been popular ever since it came out in 2003, and has helped hundreds of people lose their cravings for sugar and other simple carbs. Once the cravings are under control, it's easier to stick with your diet and regain your health.

Weight Lifting for Absolute Beginners – A guide to lifting weights for strong muscles and bones.

The Easy-Does-It Diet – A guide to creating your own delicious and healthy frozen diet meals. Eat healthy, low-fat meals without paying extra for store-bought frozen diet food.

Disclaimer: This site and the articles contained here are for information purposes only. The authors have made every effort to make sure the information is accurate, but no health decisions should ever be made based on this or any other website. Please contact your doctor before starting any diet or exercise program.