Finding out whether or not weight loss surgery will be covered by insurance is critical before formal enrollment into our program. The following are general guidelines:
Medicare currently covers the Lap Band® and the gastric bypass with no pre-certification necessary. At this time, Medicare does not cover the Gastric Sleeve procedure. Medicare does not give prior approval for surgery, so a denial is still possible before and after surgery. Please remember that Medicare covers only 80 percent of a hospital stay; therefore, we strongly encourage Medicare beneficiaries to obtain additional insurance coverage.
We accept Medicaid from Massachusetts but not from other states. A very rigorous set of guidelines must be met for patients to qualify for gastric bypass. Lap Band® and Gastric Sleeve procedures are not yet covered by Medicaid. Specifically, patients must have documentation of recent physician-supervised weight loss attempts.
Insurance coverage for weight-loss surgery varies depending on the individual patient's insurance plan. Gastric bypass, Gastric Sleeve, and Lap Band® surgery are covered benefits by many insurance companies, depending upon the type of policy you have and its terms. Insurance policies vary even though they may have been issued by the same insurance company.
Patients are advised to review their individual insurance policies to understand what insurance benefits are covered. Our clinic's policy is to utilize NIH criteria; however, specific guidelines required by insurance companies for coverage of gastric bypass surgery may not correspond exactly. Financial counseling and pre-authorization from insurance companies needs to be secured before surgery can be performed.
Self-Pay (no insurance coverage)
Some patients may choose to pay for the surgery on a self-pay basis. These arrangements can be made by speaking directly with the surgeon's administrative assistants. There are three procedure fees to consider, the physicians, your hospital stay, and the anesthesia, totaling approximately $30,000.
If you receive a denial of insurance coverage by your insurance company, you should not consider this to be a "definite no." In many cases, providing additional detailed information, in the form of an appeal letter, will result in a denial being overturned. If your insurance carrier remains unreasonable, you may want to consider writing your legislator or seeking legal assistance. Legal assistance can be obtained through a local attorney, via www.obesitylaw.com.