To determine if your insurance policy provides coverage for the weight loss surgery, you should refer to your insurance policy booklet or call your customer service representative. Typically, there are two sections that describe the extent and limits of coverage. The first is usually called 'What Is Covered' or 'Covered Expenses.' These are the healthcare benefits for which the company will pay. Look for statements such as, 'Surgery for the treatment of obesity is covered when deemed medically necessary,' or 'Surgery for the treatment of obesity is (specifically) excluded except when medically necessary.' If this surgery is a covered benefit when medically necessary, then it should be covered when patients meet national guidelines for care for morbid obesity. See general eligibility requirements below.

 

General Insurance Eligibility Requirements

a. 18 years of age

b. 2-5 year history of disease

c. BMI greater to or equal to 40 OR BMI; BMI greater to or equal to 35 with at least one comorbidity

d. 3-6 month medically supervised diet and exercise program

e. Nutritional evaluation

f. Behavioral evaluation

 

The other section is 'What Is Not Covered' or 'When the Plan Does Not Pay Benefits.' In this section, look for any statement that the company excludes coverage for weight control, for the treatment of obesity, for the surgery for weight control, or for the complications of the surgery for weight control. Some policies will outright exclude bariatric surgeries. Others may have certain parameters around which bariatric procedures they cover and how much of the costs they cover.

 

For your reference, below is the medical policy summary for each respective insurance plan. Upon determination that you have a benefit for the surgical treatment for obesity, you may assess your health plans general surgical requirements from the list below.