What Insurance Covers Bariatric Surgery​

Bariatric surgery, also known as weight loss surgery, refers to various surgical procedures performed to help people with obesity lose weight. These procedures, such as gastric bypass, gastric sleeve, and lap band surgery, reduce the size of the stomach and change how the digestive system works. As a result, bariatric surgery can lead to significant and sustainable weight loss for severely obese patients.

However, bariatric surgery can be quite expensive, with costs often ranging from $15,000 to $30,000 depending on the type of procedure. As a result, checking whether your health insurance policy covers bariatric surgery is extremely important prior to scheduling any procedures. The good news is that today, many group health plans and Medicare policies provide coverage for bariatric surgery, considering it a medically necessary procedure given the benefits for obesity-related conditions. However, the specific coverage rules, requirements, limitations, and costs can vary greatly across different insurance providers.

Insurance Coverage Basics​

Over the past 10 to 15 years, insurance coverage for weight loss surgery has expanded significantly. As research demonstrated the safety and effectiveness of bariatric procedures for long term weight loss, more insurance companies started covering surgery, considering it a medical necessity rather than an elective cosmetic procedure.

However, coverage policies differ widely, and some insurers still view bariatric surgery as experimental or optional. Key factors impacting coverage include:

  • Type of bariatric procedure being performed - gastric sleeve and gastric bypass tend to have the highest coverage rates
  • Specific exclusions, limitations, and criteria set by the insurance provider
  • Whether clinical criteria for medical necessity are met
  • Using in-network facilities and bariatric surgeons
  • Deductible amounts and out-of-pocket cost sharing
Always check directly with your insurance plan to understand the exact bariatric surgery coverage details before scheduling any procedures. Getting insurance approval for bariatric surgery is a critical first step.

Medicare Coverage​

Medicare Part A and Part B provide limited coverage for bariatric surgery today, but the criteria are strict. To qualify for Medicare-covered bariatric surgery, you must meet these rules:

  • Have a body mass index (BMI) of 35 or higher with at least one obesity-related health condition, like type 2 diabetes or high blood pressure
  • Have documentation from your physician that other supervised weight loss efforts have failed
  • Get approval in advance after your bariatric surgeon provides clinical details to Medicare
In addition, Medicare only covers certain bariatric procedures performed at facilities certified by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). These restrictions aim to ensure patient safety and positive outcomes. Out-of-pocket costs can still be significant with Medicare too, as Part A and Part B have deductibles along with 20% coinsurance on the Medicare-approved amount after the deductible.

Some Medicare Advantage plans offer enhanced bariatric surgery benefits beyond original Medicare, but policies are specific to each plan.

Medicaid Coverage​

Medicaid coverage for weight loss surgery varies considerably across different states. Some state Medicaid programs cover gastric sleeve or gastric bypass procedures, while others provide little or no coverage. Most state Medicaid policies that cover bariatric surgery have strict eligibility rules regarding body mass index (BMI) thresholds and require prior authorization along with extensive documentation that the surgery is medically necessary. Out-of-pocket costs for patients also differ by state.

Private Health Insurance Coverage​

Many group health insurance plans provided by employers offer bariatric surgery benefits today, as do individual health plans purchased through the insurance marketplace. But specific coverage details can vary greatly. Most insurers require prior authorization for bariatric procedures and proof that the surgery is medically necessary. Some plans only cover certain types of bariatric surgery, have requirements around using in-network hospitals and surgeons, or exclude experimental procedures.

Deductible amounts and coinsurance rates for bariatric surgery also differ significantly across plans. High deductible plans could leave you with over $10k in out-of-pocket costs for a procedure. Self-insured employers also have flexibility around limiting bariatric coverage policy. Always check your insurance documentation for exclusions.

Conclusion​

While bariatric surgery coverage was historically limited, today most major insurance plans cover weight loss surgery options like gastric bypass and sleeve gastrectomy, given the benefits for chronic obesity. However, coverage rules, medical necessity criteria, procedure types, and out-of-pocket costs can vary greatly depending on your specific health insurance policy. Thoroughly researching your coverage details for bariatric surgery beforehand is crucial, as surgery can be extremely expensive without insurance. Getting insurance approval is a critical first step before moving forward with weight loss surgery.