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Insurance Coverage for Bariatric Surgery

Bariatric Surgery General Insurance Information

Insurance coverage for bariatric surgery is often determined on a case-by-case basis. The Scripps Clinic, Pacific Bariatric staff can assist you with the necessary paperwork as it relates to your individual insurance company and plan. We accept a number of insurance plans. Please call our staff to discuss your individual situation: (800) 267-7212.

The information provided below is for general purposes only. Please contact your insurance company to find out about specific requirements related of your coverage.

Submission Requirements for Most Weight Loss Surgeries

If bariatric surgery costs are covered by your insurance plan, the next step is to find out the patient criteria and medical requirements for the procedure. Insurance companies often follow the National Institutes of Health (NIH) guidelines in determining whether or not a patient should be considered eligible for weight loss surgery coverage. The NIH guidelines state that weight loss surgery may be an option for patients who 1) have failed with other weight loss treatments and 2) have a BMI of 40 or greater, or 3) have a BMI of at least 35 and co-morbidities, such as type 2 diabetes, sleep apnea, hypertension, etc.. You can check your BMI here with our BMI Calculator.

Provide Documentation of Previous Weight Loss Attempts

Since weight loss surgery is considered the last method of treatment for obesity, you will need to provide documentation to the insurance company of previous weight loss attempts. Typically you will need to have been overweight at least five or more years. Pull together your receipts and weight loss records and send copies to the insurance company. You need to show them proof that you have exhausted all other weight loss methods including commercial diet programs (such as Weight Watchers and Jenny Craig), exercise programs and weight loss medications. Many insurance companies also require records showing 6 to 12 months of a continuously medically supervised diet. If you have not yet met this requirement, you should start a program immediately. The more documentation you can provide the better your chances of getting approval.

Establish a Medical Necessity for Weight Loss Surgery

In order to verify that you meet the patient criteria for weight loss surgery, your primary care doctor and/or bariatric surgeon will need to send a Letter of Medical Necessity to the insurance company. The Letter of Medical Necessity is a statement of your height, weight, BMI, health conditions, medical records, previous weight loss attempts, psychological exam results, medical necessity for weight loss, and your doctor's support and recommendation for bariatric surgery.

Appealing Denials for Weight Loss Surgery

If coverage has been denied upon the initial prior authorization request, you can appeal by addressing the specific reasons why your request has been denied. Many times the reasons for the denial are matters which can be contested and/or satisfied during the appeals process. Pacific Bariatric’s office staff can work with you through this process.

Appealing Weight Loss Surgery Exclusions

If your insurance plan has an exclusion for weight loss surgery, it may still be possible to get approval of your obesity co-morbidities. Insurance policies often exclude benefits for "obesity surgery" or surgery for the "treatment of obesity." The basis of the appeal would be your doctor's recommendation that bariatric surgery is the best method of treatment for your life-threatening health condition, such as diabetes, high blood pressure, heart disease, or severe sleep apnea. Since these health conditions are usually covered by your insurance policy, you may succeed in getting approval for bariatric surgery as a treatment for one of these conditions.