Navigating the Long Game of Bariatric Weight Loss Surgery Coverage
Bariatric weight loss surgery has long been considered effective , so I was dismayed when I recently read about its relatively high denial rates If you or someone you know is on the path to bariatric weight loss surgery, then this post will help you plan, budget, and avoid problems. The key theme is effective management of the “long-game”; stay on top of the many steps during the months- and sometimes years- long process.
Bariatric weight loss surgeries remain popular (over 270,000 in 2023) despite lower volumes in recent years. The rise of GLP-1s, which are more widely used (up to 12% of U.S. adults) has likely negatively impacted the volume of bariatric surgeries. The long-term interplay between the two, though, is being watched. For example, certain patients may ultimately use both.
First, confirm your plan covers it
When it comes to your insurance coverage, you're going to want to first check that the surgery is in fact covered by your policy. Many employers actually exclude it from their plans. And coverage varies by insurance type (examples of health insurance types are commercial, marketplace, Medicare, Medicaid, and Tricare). How do you do this?
Make sure you understand which specific type of bariatric surgery your provider recommends, because it may impact your coverage.
Checking your schedule of benefits and other plan documents is always a good first step, but the fact of the matter is it may not be mentioned there. Insurers rely on medical policies for many services, and that’s where the details may be found. By reference, those policies are part of your plan. More on medical policies below.
If you can’t confirm coverage by reviewing your documents, then your best bet is to contact your health plan and ask. If you can chat with an agent in your member portal, then that's a great way to avoid long wait times (depending on the time of day and day of week). Chat also allows you to easily document your interactions. I would NOT rely on a bot for this topic.
Ask the agent if bariatric weight loss surgery is covered by your plan. If it is covered, then you can move on to the nitty-gritty
Next, understand the steps you must follow
Ask the agent:
What types of surgeries are covered?
What are your out-of-pocket expenses? In insurance speak, that means co-pays, deductibles, and coinsurance. Most people will be forced to pay for a portion of the procedure. This info is only part of the cost puzzle - more below.
Confirm the providers on your care team are not only in-network, but approved for the procedure. For example, some Blue Cross plans limit procedures to doctors in their "Blue Distinction" program. You may need to repeat your inquiry if your care team changes.
Note too that certain providers can be in-network while their teammates at the same facility are not. This often arises with anesthesiologists. Look up the No Surprises Act and its protections. It does not protect you if you knowingly use an out of network facility.
What steps are required prior to approval of the surgery? Health plans will require you to tick boxes before they pay for the procedure. For example, you may be required to participate in nutritional counseling. Ask the agent to send you the medical policy.
Write down the time you called, who you spoke with, and any and all information conveyed to you. Do NOT be afraid to say “I don’t understand. Can you please explain further?” Don’t ignore any unease you feel about the accuracy of the information you’re being provided. As annoying as it may be, you can always call back and ask the same questions - you’ll almost certainly be connected with a different agent.
You can usually find medical policies by googling "Your insurance company bariatric surgery medical policy." Here’s an example . It's a long, detailed document. Find the coverage criteria - here’s a snippet from Blue Shield of California:
Bariatric Surgery in Adults With Class 2 Obesity (BMI greater than or equal to 35 to 39.9 kg/m2)
II. The following bariatric surgery procedures may be considered medically necessary for the treatment of class 2 obesity in individuals with at least 1 obesity-related comorbid condition who have failed weight loss by conservative measures:
A. Open or laparoscopic gastric bypass using a Roux-en-Y
B. Laparoscopic adjustable gastric banding
C. Open or laparoscopic sleeve gastrectomy (SG)
D. Open or laparoscopic biliopancreatic bypass/diversion (i.e., Scopinaro procedure) with
duodenal switch (DS)
Alternatives if your plan does not cover bariatric weight loss surgery at all
Hopefully you followed the steps above and discovered this before the procedure. It’s not the end of the road:
Depending on the type of coverage you have and time of year, you may soon be able to elect a new plan - research those options.
Ask for your provider’s care team “self-pay” rates and evaluate whether you can afford them. This may run in the tens of thousands of dollars. Financing options may be available to you.
If you can not afford it on your own, then research charities that provide financial assistance.
You can also explore medical tourism, which means travelling elsewhere to undergo a procedure.
Discuss your coverage with your care team
Bariatric weight loss surgeries are well-established enough that most providers understand the process. Regardless, it’s worth speaking with them after you have the information above to ensure everyone is on the same page. Medical providers often get tripped up because the coverage criteria is so detailed and because of the different types of surgery.
Doctor - health plan alignment issues to keep your eye on:
Documentation requirements. Really important; this often delays approvals for many procedures.
BMI thresholds required for approval, which have evolved over time.
Co-morbid condition requirements, which are typically connected to the BMI thresholds, A co-morbidity is the simultaneous presence of two or more diseases or medical conditions. Here are examples from Blue Shield of California
• Asthma
• Cardiovascular disease
• Certain types of cancer (e.g., colorectal cancer)
• Type 2 diabetes
• Dyslipidemia
• Gastroesophageal reflux disease (GERD)
• Hypertension
• Infertility
• Male hypogonadism
• Mental health (depression)
• Metabolic syndrome
• Nonalcoholic fatty liver disease (nonalcoholic fatty liver and nonalcoholic steatohepatitis)
• Obstructive sleep apnea
• Osteoarthritis
• Polycystic ovarian syndrome
• Prediabetes
• Stroke
• Urinary stress incontinence
Just like interactions with your health plan, document all of your interactions with your care team. Get the records of the important steps in the process, like test results.
And if your coverage changes during the lead up to the actual surgery, then take the extra steps to double-check your updated coverage and to ensure your care team is aligned with your new plan.
It is covered but my plan denied me
Appeal, appeal, appeal!
I won’t deep dive into the appeals process in this post, but briefly - and this applies to any service:
You need to understand why they are denying it; only then can it be corrected
Look at your Explanation of Benefits for information (if the denial occurs after the procedure is performed). Specifically, “What you Owe”. It may say zero. If it does, it’s likely an issue that your provider needs to correct.
Coordinate with your care team. For example, your plan may need additional documentation to approve.
If your health plan is provided by your employer or a family member’s employer, find out if it’s a self-funded plan. If it is, then your employer may have discretion that can be leveraged.
Follow the deadlines of the appeals process.
Counterforce Health has a good post about appealing bariatric surgery denials
Budget
Once you understand the out-of-pocket shares for your bariatric weight loss surgery from your plan, you can then estimate your costs.
Ask your provider’s office for a cost estimate of the procedure. While you’re at it, ask them for the CPT codes of the specific procedure you’re planning and write that down; you’ll need it in case of any insurance or medical billing problems after the procedure. You can also use them to get cost estimates from an independent source like Fair Health.
Your plan likely has an annual out-of-pocket maximum. This means you do not pay any more if you exceed that maximum.
Your deductibles and out-of-pocket maximums reset at the beginning of a new "benefit" year, usually January 1.
Plan for associated pre- and post- surgerty doctors visits, which have their own copays, deductibles, and coinsurances. You'll be able to find these ones in your member portal or plan documents.
Plan and budget for your new diet.
Don’t overlook the potential costs of related procedures after your bariatric surgery, such as skin removal. Health plans typically address this one with separate medical policies and coverage criteria. Repeat the same game plan if you go down this road: ask and confirm coverage and its requirements, document your medical and insurance interactions and histories, and work with your care team to ensure criteria is met.
Likewise, if certain complications occur, then revision surgery may be necessary. Understand the costs and coverage requirements ahead of time.
Resources
Rest assured that your feelings are valid if you find yourself frustrated with the process. “I can’t believe I have to manage this while dealing with my health!” Though there is debate over the effectiveness of these requirements, they are what they are. Do not give up. Seek support when you need it.
Here’s a few ways to connect to people who have shared experiences:
Patient advocates can also assist you throughout any part of this journey.
You can do it!
Navigating bariatric surgery coverage can feel overwhelming, but taking it step by step makes the “long-game” manageable. The key is staying proactive: verify coverage early, document everything, keep your care team informed, and don't hesitate to ask questions when something isn't clear. Remember, you're advocating for your health. The time you invest now in understanding your coverage and meeting requirements will pay off by helping you avoid unexpected costs and delays down the road. And if you hit roadblocks, know that you have options and a community of people who've navigated this same journey.
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