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Insurance Coverage

Who will pay for the procedure?

Insurance coverage is an obvious and important factor to consider when exploring weight loss surgery.

In most states, legislation requires insurance companies to provide benefits for weight loss surgery when patients meet the National Institutes of Health (NIH) criteria. But even though insurance coverage is widespread, you should prepare for a lengthy approval process.

Follow the steps below to increase your chances of being approved for coverage:

  • Read and understand your insurance company's "certificate of coverage." You can get it from your employer's benefits administrator or your insurance company directly. *

  • Get a referral from your primary care physician if necessary. Even if you don't need one, you must have your doctor's support.

  • Keep accurate, detailed records and save receipts.

  • Document every visit to health care professionals for obesity-related issues, including weight loss programs, diet centers, and fitness clubs.

The Insurance Authorization Process

Here's how it works: Your surgeon will send a letter to your primary care physician asking your doctor to write a letter to establish the "medical necessity" of weight loss surgery by proving:

  • You are morbidly obese and have a BMI of 40 or higher.

    • Or you have a Body Mass Index (BMI) of 35 or more, and you're experiencing obesity-related health conditions, such as high blood pressure or diabetes.

  • You have been obese for the past five years or longer.

  • You have attempted, under your physician's care, other methods of weight loss for at least two years. These may include: Behavior Modification, Optifast, Medifast, Drug Therapy, or commercial weight loss programs.

  • You have co-morbidities (if you have any)—such as hypertension, diabetes, sleep apnea, degenerative arthritis, heart disease—that merit consideration of medical necessity for surgery.

The letter should also mention:

  • If you have any significant liver, kidney, or gastrointestinal disease.

  • Whether you have a history of alcohol or substance abuse.

  • That a thyroid test has been ordered and results will be sent to your surgeon.

*The only time any insurance has not covered the surgery (when a patient meets criteria) is when there is a specific exclusion of benefits for treatment of morbid obesity.