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printer-friendly versionUnderstanding Bariatric Insurance Coverage and Financing
Many health insurance plans, including Medicare and most Medicaid plans, cover the REALIZE Band. Since health insurance coverage varies, only an insurance provider can confirm a patient?s coverage for weight loss surgery.
When health insurance doesn?t fully cover the cost of weight loss surgery, or for individuals who don?t have health coverage, financing options are available from lenders. Some financing options include a credit card, personal line of credit, home equity line of credit, or mortgage. Ask lenders about a range of options, such as flexible monthly payments and reasonable interest rates, secured and unsecured loans, higher approval rates, and quick application and approval processes.
The cost of gastric banding
The cost of the procedure is determined by the bariatric surgeon and the hospital where the procedure is performed. The cost of gastric banding can range from $10,000 to $17,000. Costs vary depending on the hospital fees and surgeon fees. Individuals with bariatric surgery coverage are only responsible for the fees not covered by insurance.
The following steps can be helpful when working with an insurance provider.
Step 1: Find out if bariatric surgery is covered.
Step 3: Follow up to ensure that the insurance company has received pre-approval documentation.
Step 4: Request written confirmation of approval or denial of coverage.
Step 4a. File an appeal after a denial.
Step 5. What to do if an appeal is denied.
| Step 1: Find out if bariatric surgery is covered. |
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To determine coverage for bariatric surgery, look at the insurance policy or plan benefits statement, or call the insurance provider directly. Calling the insurance provider is often the best way to get answers, because insurance documents are often written in a legal style and may be difficult to understand. Patients will need answers to the following questions:
The answers to these questions will confirm whether bariatric surgery is a covered benefit. Individuals are also advised to find answers to these questions:
Karen Schulz, a program coordinator for a bariatric clinic, offers this advice: ?We usually tell our patients to be very specific about the procedure they?re interested in, and then ask if there are any exclusions for that procedure. Sometimes insurance companies will just say no, we don't cover bariatric surgery. However, what they don't tell you is that it says ?unless medically necessary.? So you want to make sure to ask ?would it be covered if it's medically necessary??? |
| Step 2: Work with the bariatric practice to gather the required documentation for pre-approval, if surgery is covered. |
| Pre-approval is usually required for weight loss surgery to ensure the procedure is covered. It is best to contact the insurance company in writing and request a determination of coverage amount before the procedure is performed. The surgeon?s office may submit the required information to the insurance provider on behalf of a patient.
The National Institutes of Health requirements include having a Body Mass Index (BMI) greater than 40 or BMI greater than 35 with co-morbidities (diabetes, high blood pressure, etc.), and being 18 years of age or older. In many cases, patients are required to prove that their previous weight loss attempts have been unsuccessful before weight loss surgery will be approved. |
| Step 3: Follow up to ensure that the insurance company has received pre-approval documentation. |
| If pre-approval authorization is not received 1 week after submission, patients should call the insurance company to confirm that the materials were received. |
| Step 4: Request written confirmation of approval or denial of coverage. |
| Approval means that a patient is on the path to getting bariatric surgery. However, being denied is a common first response from insurance companies. Don?t give up. Call the insurance provider and ask why the procedure is not covered and insist on a written denial. Request that the provider reconsider the request. |
| Step 4a. File an appeal after a denial. |
| The insurance provider can provide the necessary steps required to file an appeal. Consider working with the bariatric practice to discuss the next steps in appealing for coverage. They can help to navigate the appeal process. The Obesity Action Coalition (OAC) also offers help in navigating the bariatric insurance appeals process. OAC offers comprehensive information in their brochure, ?A Guide to Seeking Weight Loss Surgery? (PDF).
A few weeks after submitting an appeal, follow up with the provider to inquire about the status of the appeal. |
| Step 5. What to do if an appeal is denied. |
| Those who are denied coverage by their insurance provider after an appeal can consider alternative financing options, such as a credit card, personal line of credit, or a home equity line of credit. Individuals can also speak with their employers for help getting an individual approval for surgery, or call the state insurance department to register a complaint. Complaints do not guarantee that coverage will be obtained, but they may help to change reimbursement policies for bariatric surgery in the future. |
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© Ethicon Endo-Surgery, Inc. 2009 DSL#09-1077 This information is provided by Ethicon Endo-Surgery, Inc. Ethicon Endo-Surgery is not responsible for any other content on this Web site. The REALIZE® Adjustable Gastric Band is used in morbidly obese adult patients for significant long-term weight loss. It may not be right for individuals with certain digestive tract conditions. All surgery presents risks. Weight, age, and medical history determine your specific risks. Ask your doctor if bariatric surgery is right for you. For more information, visit the official site for the REALIZE® Adjustable Gastric Band, www.REALIZE.com, or call 1-866-REALIZE. |
