Patient Financing for Gastric Bypass Surgery

Insurance Coverage for Gastric Bypass and Bariatric Surgery

In many states, there are laws in place that require insurance companies to provide benefits for weight loss surgery when a patient meets the National Institutes of Health (NIH) criteria. However, obesity surgery patients should still prepare themselves for what is commonly a long and complicated approval process. The best chance for obtaining insurance coverage for the cost of LAP-BAND� and gastric bypass surgery comes from working diligently in cooperation with your bariatric surgeon and other experts.

WILL MY INSURANCE COVER THE GASTRIC BYPASS SURGERY PROCEDURE?

Most insurance companies will pay for gastric bypass surgery procedures that are medically necessary. Morbid obesity is a life threatening disease and it is normally covered.

The Insurance Approval Process

There several helpful things that you can do to smooth along the insurance approval process. Following the steps below may be able to increase your chances of being approved for obesity surgery coverage.

It is important that you read and understand your insurance company's "certificate of coverage." You can get it from your insurance company directly or from your employer's benefits contract.
Get an obesity surgery referral from your doctor. You must have your doctor's full support.
Save all of your receipts and always keep accurate, detailed records.
Carefully document each visit you make to doctors and other healthcare professionals for obesity-related issues. In addition to doctor's appointments, this includes visits to diet centers, fitness clubs, and weight loss programs.

Aetna Insurance is now asking for the patients entire medical work-up along with the pre-authorization request as well as documented weight loss attempts supervised by a physician for the last 2 years. They also want documented weight history for the last 5 years.

The Insurance Authorization Process

The lengthy authorization process will begin when your bariatric surgeon sends your primary care physician a letter asking him or her to verify the "medical necessity" of your surgery for obesity. Your doctor can establish this by proving that any of the following apply to you:

You are morbidly obese with a BMI (body mass index) of 40 or higher
You have suffered from morbid obesity for at least the past five years
You have attempted, under your physician's care, other methods of weight loss for at least two years
You have co-morbidities - such as hypertension, diabetes, sleep apnea, degenerative arthritis, and heart disease - that constitute medical necessity for obesity surgery
You do not have major psychiatric or emotional problems

Any of the following that apply to you should also be mentioned:

You have significant liver, kidney, or gastrointestinal disease
You have a history of alcohol or substance abuse
A thyroid test has been ordered and results will be sent to your surgeon

The Appeals Process

Even if your pre-authorization for obesity surgery coverage is denied by your insurance company, there is still a chance that you can receive full or partial coverage for the cost of your bariatric surgery through the appeals process. During the appeals process, you may contest each reason your insurance company has given for denying coverage. It is critical that you submit your appeal quickly in order to have the best chances for a successful outcome. In some instances it may be helpful to employ the services of an insurance advocate or lawyer to help you effectively navigate the appeals process. Your insurance company may limit the number of times that you can appeal for weight loss surgery coverage, so make sure that you understand the guidelines set in your "certificate of coverage."

Obesity, Medicaid and Medicare

Medicaid does not cover obesity, and under Medicare, hospital and physician services for obesity are clearly excluded. Medicaid is a government program that provides health insurance to qualified individuals whose income level is below a certain point. Recipients of Medicaid are primarily women and children who are poor and members of minority groups. Given the high prevalence of obesity among those populations, it could be presumed that many Medicaid recipients are likely to have obesity. Medicare provides health insurance coverage to elderly citizens and disabled Americans who qualify by meeting criteria of the Social Security Administration (SSA) and completing a two-year waiting period.

Medicaid

In 1990, Congress enacted the Omnibus Budget Reconciliation Act (OBRA), which funds state programs to provide pharmaceutical products to Medicaid recipients.

A State may choose to exclude or restrict drugs or classes of drugs, or their medical uses for certain purposes. A State choosing to include outpatient drugs within its Medicaid program must cover, for their medically accepted indications, all Food and Drug Administration (FDA) approved prescription drugs of manufacturers that have entered into drug rebate agreements, with a few limited exceptions.

Exceptions include drugs when used for: anorexia, weight loss or weight gain; to promote fertility; for cosmetic purposes or hair growth; for the symptomatic relief of cough and colds; or to promote smoking cessation.

As a result of OBRA, the Department of Health and Human Services ordered states to cover Viagra for the treatment of erectile dysfunction while continuing to exclude anti-obesity agents.

Nine states cover anti-obesity pharmaceutical products including Alaska, California, Kentucky, Montana, North Carolina, Oregon, Rhode Island, Washington and Wisconsin.

One state, Arizona, covers products by specific managed health care plan.

In 23 states, there is no specific language regarding coverage under Medicaid.

In 29 states, anti-obesity products are specifically excluded in state Medicaid programs.

Medicare

The Medicare Coverage Manual defines obesity and the justification for certain treatment coverage by stating that:

Obesity itself cannot be considered an illness. The immediate cause is a caloric intake, which is persistently higher than caloric output.

Program payment may not be made for treatment of obesity alone since this treatment is not reasonable and necessary for the diagnosis or treatment of an illness or injury.

However, although obesity is not in itself an illness, it may be caused by illnesses such as hypothyroidism, Cushing's disease, and hypothalamic lesions. In addition, obesity can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Therefore, services in connection with the treatment of obesity are covered when such services are an integral and necessary part of a course of treatment for one of those illnesses.

Medicare�s limited coverage of obesity is difficult to understand when considering that it does cover services such as inpatient and outpatient alcohol detoxification and rehabilitation, inpatient and outpatient drug rehabilitation, and services for sexual impotence. It also covers chemical aversion therapy for the treatment of alcoholism even though the FDA has not approved the drugs commonly used in chemical aversion therapy for this application.