Most health insurance plans cover bariatric surgery, or weight loss surgery, for patients who meet specific criteria. The most common types of weight loss surgery covered by insurance include:
- Gastric bypass
- Sleeve gastrectomy
- Biliopancreatic diversion with duodenal switch
- Single-anastomosis duodenal-ileal bypass with sleeve gastrectomy
Typically, patients need a body mass index (BMI) of at least 40. However, some patients with a lower BMI and a qualifying comorbidity are also eligible. Most insurance companies require patients to undergo a weight management program and dietary and psychological assessments.
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When is Bariatric Surgery Necessary?
Doctors often recommend bariatric surgery for patients diagnosed with morbid obesity who have unsuccessfully attempted other methods of weight loss. Bariatric surgeries can help minimize or prevent patients from developing related conditions such as diabetes and heart disease. The following types of bariatric surgery physically alter the stomach to restrict or divert the absorption of food and reduce weight gain.
Types of Bariatric Surgery
Gastric Bypass (Roux-en-Y)
Gastric bypass is the most common type of weight loss surgery. During the procedure, your stomach is compressed in multiple places using surgical staples to force food directly into the small intestine, effectively bypassing the larger part of your stomach. This metabolic surgery affects how your body processes hunger and fullness and absorbs nutrients.
Sleeve Gastrectomy
Sleeve gastrectomy is common among patients with complex medical issues. The process removes approximately 80% of the stomach and forms a “sleeve” from the remaining tissue, reducing absorption capacity to roughly 4 ounces. Many surgeons perform the procedure laparoscopically, inserting instruments through an incision in the abdomen to surgically reduce the stomach size.
Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
This type of bariatric surgery is similar to a sleeve gastrectomy in that it removes most of the stomach. It also diverts food like gastric bypass but connects the stomach to the duodenum, or the top lobe of the small intestine. This surgery is less common, reserved primarily for patients with BMIs over 40 or advanced comorbidities, including Type II Diabetes.
Single-Anastomosis Duodeno-Ileal Bypass With Sleeve Gastrectomy
This procedure involves a simplified BPD/DS combined with a sleeve gastrectomy to divert food through a shortened “sleeve” into the small intestine. Still an emerging weight loss technique, this method attracts similar candidates but tends to incur less risk for complications than a routine gastric bypass or duodenal switch procedure.
Why It’s Done and Who It’s For
Weight loss surgery can drastically lower the BMI of morbidly obese patients and reduce their risk of developing life-threatening, chronic medical comorbidities. Since weight loss surgery is permanent and comes with a risk of complications, it requires extensive pre-authorization. This surgery is often a last resort.
How Does Health Insurance Cover Weight Loss Surgery?
Many factors affect whether your weight loss surgery is covered by insurance, such as meeting your insurer’s BMI and other physical and psychological requirements. Insurers also generally cover routine, follow-up outpatient care after surgery. Some insurers may cover post-op excess skin removal. However, this and other procedures like tummy tucks and breast augmentations are considered cosmetic and usually aren’t covered by insurance.
Eligibility Requirements
Insurance coverage requirements for bariatric surgery include being 18 or older and having a BMI between 35 and 40. You must also document previous long-term weight loss efforts and undergo psychological testing and an insurance-mandated weight loss program. Candidates must be non-smokers at the time of surgery, with no history of substance abuse.
How Much Does Weight Loss Surgery Cost?
The cost of bariatric surgery varies significantly by type and scope. For example, a simple lap band procedure on an otherwise healthy patient costs less than a more complicated biliopancreatic diversion surgery on a more vulnerable candidate. What your plan covers and whether or not you have met your deductible can also affect costs.
According to the American Society for Metabolic and Bariatric Surgery, bariatric surgery ranges between $17,000 to $26,000. Mandates across nearly half of all states require ACA Marketplace plans to cover bariatric surgery as a medical necessity for qualifying patients. Your specific benefits depend on location, network, and deductible amount.
How Medicaid and Medicare Cover Weight Loss Surgery
Medicaid and Medicare weight loss surgery coverage differ slightly from traditional health insurance plans. Like private or employer-funded insurance policies, Medicare candidates must prove their bariatric surgery is medically necessary for approval. However, Medicare or Medicaid may only cover certain types of weight loss surgery in your state.
Medicare recipients must meet their annual Part A and B deductibles and obtain pre-authorization to be eligible for weight loss surgery. Once approved, Medicare will pay 80% of the cost of care after deductible. Bariatric surgery options for Medicaid beneficiaries differ widely from state to state based on factors like surgeon availability and network size.
Alternatives to Weight Loss Surgery
Depending on your weight loss goals, your doctor may recommend a less-invasive or non-surgical alternative to bariatric surgery, including the options below.
Gastric Balloon
This procedure inserts a balloon in the stomach to mimic the sensation of fullness and decrease the overall capacity of the small intestine. The saline-filled balloons can typically be inserted non-surgically and may stay in place temporarily for up to 8 months. They serve as an alternative to, or to help lose weight in preparation for, bariatric surgery.
AspireAssist Device
An FDA-approved AspireAssist device can be inserted into the stomach to inhibit calorie intake. AspireAssist drains some digested food from the stomach through a tube after each meal. The device can be implanted non-surgically and is reversible if necessary, making AspireAssist a less invasive and more flexible alternative to bariatric surgery.
Endoscopic Sleeve Gastroplasty, Gastric Plication
This procedure is minimally invasive compared to gastric sleeve surgery but follows the same principle. Surgeons can use endoscopic instruments to reduce stomach volume to aid in drastic weight loss. The stomach is folded onto itself and then sutured to a smaller size.
Endoscopic Gastric Bypass Revision
This revisional procedure can help patients jump-start the weight loss process again after undergoing bariatric bypass surgery. Endoscopic gastric bypass revision further reduces the stomach size, enabling patients to lose any weight they may have gained since their initial bypass surgery.
Weight Loss Medications
Patients with a documented history of morbid obesity might consider weight loss medications, provided the drugs are FDA-approved and prescribed by a licensed medical professional. Medically-assisted weight loss often combines appetite suppressants and absorption inhibitors with holistic diet, fitness, and behavior modification counseling.
Behavioral Changes
Some patients looking for an alternative to bariatric surgery may benefit from undergoing a significant lifestyle change. Healthy behavioral changes aimed at losing weight and reducing your risk for BMI-related medical conditions include consulting with a nutritionist and personal trainer to overhaul your long-term diet and fitness routines.
Financing Options for Weight Loss Surgery
If you do not meet the insurance criteria for bariatric surgery, you may still pursue alternative financing options. Many providers offer installment plans or financing options that enable patients to pay their medical bills over time. You may also qualify for discounts directly through your provider.
All in All
Bariatric surgery offers a solution for patients diagnosed with morbid obesity who have unsuccessfully attempted other weight loss options over at least 6 months. Weight loss surgery is covered by insurance for patients whose doctor recommends bariatric surgery as a medically necessary last resort.
Those seeking insurance coverage must have a BMI of 35-40, have exhausted all other weight loss attempts, undergo physical and psychological evaluations, and complete a mandatory pre-op weight loss program. Depending on their medical needs, patients may be a fit for various surgery types.