Health Insurance Coverage
Insurance Coverage Additions
Most insurance carries will cover bariatric
surgery for those patients that meet the NIH consensus conference
criteria. Basically, these guidelines suggest that bariatric
surgery is most beneficial to those patients whose BMI exceeds
40, or those with BMI over 35 with significant obesity-related
medical conditions.
The insurance process does vary from state to state, so it
is best to discuss this with your local surgeon. Most surgeons
will actively participate in pre-approval, along with your
primary care provider, to help you navigate the process as
easily as possible.
HMO & PPO:
Both HMOs and PPOs have two categories under
which bariatric surgery may fall:
- Cosmetic Procedures
- Medically Necessary Procedure
The majority of bariatric surgery procedures
will fall under the category of cosmetic procedure, and as
such, will not be covered by insurance providers.
Insurance companies use varying criteria
in order to determine if bariatric surgery is to be considered
"medically necessary." These criteria may include one or more
of the following:
- Lifestyle
Disruption: the daily activities of the patient must be
disrupted significantly.
- Pain:
The patient must be experiencing pain as a result of their
weight loss disorder.
MEDICARE
Medicare will generally not reimburse for
these procedures. You will have to contact your bariatric
facility to determine whether they are participating in Medicare
and whether your treatment may be covered. Any secondary and
supplemental insurance company will require Medicare to decline
the service before they will consider reimbursement.
Most bariatric clinics will offer you a variety
of payment methods. Please ask your bariatric specialist about
payment options during your consultation. For further insurance
information contact you insurance provider for coverage options.
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