Your Health Net weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.
First, try our insurance tool to quickly check your insurance coverage:
Read and click below for additional weight loss surgery insurance details.
TABLE OF CONTENTS
Click on any of the topics below to jump directly to that section
SECTION SUMMARY:
- 35+ Body Mass Index (BMI)
- Documentation of failed diet attempts
- Psychological evaluation
READ THIS FIRST
Even if your insurance company covers bariatric surgery in some plans, that does not mean that your specific plan covers it. The obesity surgery approval requirements in this section assume that weight loss surgery is covered by your specific policy.
To confirm whether your specific policy covers bariatric surgery, click here to contact a surgeon and ask for a free insurance check.
Disclaimer: The information contained on this page may not include all components of your insurance company’s medical policy and/or may not be up to date. Contact your insurance company to confirm all benefits.
In order to be approved by Health Net for bariatric surgery in the United States, you must meet the following criteria:
- Patient is between 18 and 65 years of age (unless the patient is over 65 years of age and is considered a low-risk candidate for surgery)
- For at least 2 years or greater, the patient has clinically severe obesity (morbid obesity) defined by either of the following:
- a Body Mass Index (BMI) greater than 40
- BMI between 35 and 39.9 with one or more of the following comorbidities which are generally expected to be improved, curtailed or reversed by obesity surgical treatment:
- Severe, active coronary artery disease
- Obesity-related cardiomyopathy
- Congestive heart failure
- Obstructive sleep apnea with use of CPAP or polysomnogram showing apnea-hypopnea index (AHI) of at least 15 per hour
- Pickwickian syndrome
- Type 2 diabetes mellitus
- Clinically significant asthma
- Chronic venous insufficiency with pain on weight bearing and persistent edema
- Respiratory insufficiency, as evidenced by pCO2 > 50 mmHg, FEV1/FVC < 65%, or DLCO < 60%
- Hypoxemia at rest, as evidenced by pO2 < 55 mmHg on room air
- Severe gastroesophageal reflux disease (GERD)
- Severe pain and limitation of motion in any weight-bearing joint or the lumbosacral spine documented by physical examination in association with radiologic findings showing degenerative osteoarthritis
- Patient has at least one of the following:
- Hypertension (blood pressure > 140 mmHg systolic and/or > 90 mmHg diastolic measured with appropriate size cuff) that has not responded to medical therapy
- First degree relative with premature (age < 50) cardiovascular disease
- Hypercholesterolemia > 240 mg/dL that has not responded to medical therapy
- Hypertriglyceridemia > 400 mg/dL that has not responded to medical therapy
- Low density lipoprotein (LD) >130 that has not responded to medical therapy
- High density lipoprotein (HDL) < 35 that has not responded to medical therapy
- Impaired fasting glucose > 125
- Pulmonary hypertension
- Patient has made a reasonable effort to lose weight and chart notes must document that these attempts at dietary control have been ineffective in achieving a medically significant long-term weight loss.
- Published peer-reviewed studies have shown that superobesity was the most important risk factor for perioperative complications, during bariatric surgery. Although patients undergoing bariatric procedures invariably have a history of failed dieting, preoperative weight loss can improve patient safety for these procedures. Aggressive medical therapies, such as very low calorie diets, are transiently effective for morbidly obese patients. The major limitation of medical obesity treatments for these patients is generally unsustainable weight loss rather than an inability to lose weight at all. Given these circumstances, preoperative weight loss can prove to be a reasonable approach to reduce adverse outcomes for superobese bariatric surgical patients but is not required prior to surgery
- All patients must undergo a preliminary psychological evaluation by licensed mental health care professional (LCSW, MFCC, MSW PhD) familiar with the implications of weight reduction surgery. If pathology is identified, then an evaluation by a psychologist / psychiatrist is required and the member must receive clearance before surgery is performed
Or
Patients with History of Alcohol / Hard-Core Substance Abuse
Patients with a history of alcohol or hard-core substance abuse should not be considered a candidate unless there is a record of at least one year of abstinence, which must be documented by random negative urine samples/blood alcohol levels/breathalyzer testing.
If there has been a one-year abstinence, this condition must be addressed in a psychiatric consultation.
Use this BMI Calculator to check your body mass index…
Adolescents Requirements
Patient is an adolescent between 14 and 17 years of age and all of the following criteria are met:
- Patient has made a reasonable effort to lose weight and chart notes must document that these attempts at dietary control have been ineffective in achieving a medically significant long-term weight loss
- Attainment or near-attainment of physiologic maturity (Tanner stage V) – in some cases, a bone age may be required to determine skeletal maturity as evidenced by fused epiphyses
- Hair extends to medial surface of the thighs
- No skeletal growth over last year
- For male, testicular volume greater than 20 ml; adult scrotum and penis
- For female, breast reaches final adult size; areola returns to contour of the surrounding breast, with a projecting central papilla
- Severe obesity defined as:
- A BMI of 40 or above with serious obesity-related comorbidities, including:
- Type 2 diabetes mellitus
- Benign intracranial hypertension (Pseudotumor cerebri)
- Obstructive sleep apnea
- Obesity hypoventilation syndrome
- A BMI of 50 or above with less severe comorbidities
- weight related arthropathies
- hypertension
- dyslipidemia
- venous stasis disease
- panniculitis
- urinary incontinence
- significant impairment in activity of daily living
- nonalcoholic fatty liver disease (includes steatohepatitis)
- gastroesophageal reflux
- severe psychosocial distress
- Commitment to comprehensive medical and surgical evaluations before and after surgery
- Avoidance of pregnancy for at least 1 year postoperatively
- Capable and willing to adhere to lifelong follow- up with nutritional counseling and biochemical surveillance postoperatively
- Must be able to show decisional capacity and emotional maturity in psychological evaluation and provide informed consent
- Supportive and committed family environment
Health Net’s Tanner Stage V Definition
Tanner Stage V includes all of the following characteristics:
Surgery is considered investigational and therefore not medically necessary in an adolescent when any of the following is met:
- Presence of a medically correctable cause of obesity (e.g., hypothyroidism)
- An alcohol or substance abuse problem within the previous 12 months
- A medical, psychiatric, or cognitive disability that impairs ability for adherence of postoperative diet
- Current pregnancy or breastfeeding, including planned pregnancy within the first year after surgery
- Inability or unwillingness of the patient or parents to understand the procedure and its medical consequences, including the need to maintain lifelong dietary requirements
Contraindications for Bariatric Surgery Procedures
Surgery may be denied by Health Net if the individual demonstrates one or more of the following:
- Non-compliance with previous medical care
- Symptomatic coronary artery disease
- End-stage renal disease (relative)
- Poor myocardial reserve (EF < 35)
- Significant chronic obstructive airways disease or respiratory dysfunction
- Active peptic ulcer disease
- Advanced cancer
- When drug level maintenance is critical, such as:
- Patients with seizure disorders requiring anti-seizure medications
- Patients with mental illness who require maintenance medication Bariatric Surgery
- Adjustable gastric banding surgery is contraindicated in patients with gastroesophageal reflux pre-operatively, those who plan to stay on nonsteroidal anti-inflammatory drugs and other mucosal irritating drugs
- Psychological disorder(s) of a significant degree that a psychologist / psychiatrist thinks it would be exacerbated by or interfere with the long term management of the patient after the operation, such as:
- Active substance and alcohol abuse
- Significant eating disorders
- Untreated schizophrenia
- Uncontrolled major depression
- Manic-depressive disorder
- Psychotic disorders
- Borderline personality disorder
- Mental retardation
- Psychological criteria to exclude patients from consideration for surgery:
- Active psychosis present (defined as current evidence of active psychosis and/or mental health hospitalization for psychosis within past 1 year)
- History of multiple (3 or more) suicide attempts within the past 5 years
- Alcohol use disorder within past 6 months
- Other substance use disorder within past 6 months (use of cannabis only might be an exception)
- Borderline personality disorder as indicated by medical record, clinical interview, or results of MMPI
- History of poor compliance with medical regimens appointment keeping, follow-up instructions or evidence on MBMDO or MMPIO that patient is very high risk for this
- Delay consideration for surgery pending response to further psychological treatment:
- Poorly controlled mental illness(es) or cognitive impairment that may interfere with ability of patient to comply with necessary instructions and follow up (e.g. poorly controlled OCD, severe depression/anxiety, severe bipolar disorder, dementia)
- Severe Binge Eating Disorder as measured by Questionnaire on Weight and Eating Patterns (QWEP-R) and confirmed by clinical interview
- Unstable social environment (homeless, lack of access to a kitchen, lack of social support) as assessed by clinical interview
- Very low self-efficacy/self-motivation/personal responsibility as evidenced by low Multidimensional Health Locus of Control (MHLC) scores and confirmed by clinical interview
- Other severe behavioral problems as evidenced by scores on Million Behavioral Medicine Diagnostic (MBMD) or Optional-Minnesota Multiphasic Personality Inventory (MMPI) and confirmed by clinical interview
Revision Requirements
A Repeat / Revision Surgery will be approved if it is medically necessary to correct any of the following complications:
- Roux-en-Y Gastric Bypass:
- Abdominal catastrophe – the complication of peritonitis from an anastomotic or staple-line leak
- Bowel obstruction or stricture of the stoma between the pouch and the intestines, stomal ulceration
- Protein-calorie malnutrition
- Severe metabolic complications from gastric bypass or induced malabsorption
- Internal hernias
- Infections
- Lap-Band:
- Pouch dilatation (also vertical banded gastroplasty)
- Stomach slippage
- Band erosion
- Band or tubing leakage
- Severe reflux of gastric acid causing heartburn
- There is a technical failure of the primary procedure such as dilation of the gastric pouch or gastrojejunostomy anastomosis as noted by diagnostic imaging (e.g. GI series), as well as:
- the individual experienced weight loss prior to the technical failure
- the individual was compliant with the prescribed postoperative diet and exercise programs
- Conversion to an alternative procedure if the member has inadequate weight loss which is defined as failure to lose at least 50% of excess body weight or failure to achieve body weight to within 30% of ideal body weight at least two years following the original surgery and they have been compliant with prescribed nutrition and exercise program. Body weight and BMI information is available from the National Heart Lung and Blood Institute [NHLBI) BMI tables
A Note About Revision Surgery
Inadequate weight loss due to individual noncompliance with postoperative nutrition and exercise recommendations is not a medically necessary indication for revision surgery and would not be an indication for coverage.
If Your Policy Does NOT Cover It: Seek Partial Coverage
You may be able to get part of the costs paid for by insurance even if weight loss surgery isn’t covered. It’s all about how your doctor and hospital submit your claims to your insurance company.
For example, there are many non-bariatric surgery reasons for your doctor to recommend:
- Cardiology exam
- Lab work
- Medically supervised diet program
- Psychological exam
- Sleep study
These are ordered for many reasons other than bariatric surgery and may be covered as a result. If your doctor submits one of these claims using a weight loss surgery CPT code (Current Procedural Terminology Code), your insurance is unlikely to cover it. But if your doctor uses a general CPT code, it probably will be covered.
While this may sound “sneaky”, it is an ethical practice. After all, these tests will be beneficial regardless of whether you move forward with surgery.
Health Net Contact Information and Full Medical Policy on Bariatric Surgery
- By Phone: 1-800-675-6110
- Contact Health Net
- Full Bariatric Surgery Medical Policy for Health Net
SECTION SUMMARY:
- Coverage Through Your Employer
- Individual & Family Plans
- Medicare
Before getting into the types of insurance plans, you can cut to the chase by contacting a local bariatric surgeon’s office. Most surgeons will contact your insurance company for free to confirm whether or not you’re covered.
Click here to find a local surgeon and ask them to check your insurance for you for free.
Health Net does cover weight loss surgery, but your specific policy must include it in order for you get it covered.
Following are a list of Health Net plan types and whether they cover bariatric surgery:
Weight Loss Surgery for Health Plans Through Your Work
If you work for a company that has 50 or more full time employees, it is completely up to your employer to decide whether or not to cover bariatric surgery under your health plan.
To find out whether weight loss surgery is covered by your employer’s plan, you have a few options:
- Your local surgeon will usually be willing check your insurance for free. Click here to find a surgeon near you, then call or email them to request a free insurance review.
- Ask your Human Resources department
- Contact your insurance company directly using the phone number on your insurance ID card
Weight Loss Surgery for Individual/Family Plans
The Affordable Care Act (Obamacare) requires all individual and small group plans (less than 50 full time employees) to include weight loss surgery coverage as long as it is considered an “Essential Health Benefit” in your state.
The following states DO currently consider bariatric surgery an Essential Health Benefit (bariatric surgery is covered by all individual, family and small group plans in these states):
Your State Not on the List?
If your state is NOT on the list, then weight loss surgery is probably NOT covered under your plan.
First, contact your local surgeon to be sure. For no charge, their office will contact your insurance company on your behalf to work through the details.
If your surgeon confirms that your policy does not include obesity surgery, you still have several options for making surgery more affordable. See these pages for more information:
- Weight Loss Surgery Insurance Secrets: Revised List (good tips even if your policy does not include bariatric surgery)
- Financing bariatric surgery (all of your options)
- Arizona
- California
- Delaware
- Hawaii
- Illinois
- Iowa
- Maine
- Maryland
- Massachusetts
- Michigan
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Oklahoma
- Rhode Island
- South Dakota
- Vermont
- West Virginia
- Wyoming
Regardless of whether your state is on the list, contact a qualified surgeon to request a free insurance check to verify your coverage.
To review your insurance company’s obesity surgery coverage requirements, click here to jump back up the page.
Weight Loss Surgery for Medicare Plans
All Medicare plans are required to cover the following weight loss surgery procedures:
- Gastric sleeve surgery
- Gastric bypass surgery
- Gastric banding (lap band surgery) (LASGB)
- Duodenal switch surgery (DS)
- Biliopancreatic diversion surgery (BPD)
However, special Medicare-specific criteria apply. Click here to learn more about Medicare bariatric surgery coverage.
SECTION SUMMARY:
- Gastric Sleeve
- Gastric Bypass
- Lap-Band
- Vertical Banded Gastroplasty
Please see below for the procedures Health Net covers, might cover under certain circumstances, and those that are not covered under any circumstances:
Procedures That ARE Covered
- Gastric Sleeve Surgery – Acceptable option as a primary bariatric procedure and as a first stage procedure in high risk patients as part of a planned staged approach
- Roux-en-Y Gastric Bypass – (< 100 cm) (open and laparoscopic)
- Lap-Band – (open and laparoscopic)
- Vertical Banded Gastroplasty – (open and laparoscopic)
Open Vs. Laparoscopic Surgery
Most patients who are candidates for open bariatric surgery are also candidates for laparoscopic bariatric surgery. The only significant contraindications to laparoscopic surgery necessitating an open procedure include BMI greater than 70 and hepatomegaly, due largely to the poor exposure and instrumentation afforded in these cases.
Procedures That MIGHT BE Covered
The following procedures MIGHT BE covered by Health Net:
- Duodenal Switch – only when both of the following specific criteria are met:
- Patient has a BMI greater than 50
- Construction of a common channel of 100 cm or more is planned
- Revision Surgery (either Lap-Band Revision or Gastric Bypass Revision)
- Roux-en-Y gastric bypass (RYGB) with long limb (> 100 and < 200 cm) (open and laparoscopic) – only with a BMI over 50
Procedures That Are NOT Covered
Health Net, Inc. considers any of the following procedures investigational because the medical literature indicates that studies have been inadequate to determine their efficacy and long-term outcomes:
- Gastric Balloon
- AspireAssist
- Mini Gastric Bypass Surgery
- Distal gastric bypass (very long limb gastric bypass)
- Laparoscopic re-sleeve gastrectomy (LRSG) performed after the resulting gastric pouch is primarily too large or dilates after the original laparoscopic sleeve gastrectomy (LSG)
- Fobi pouch
- Laparoscopic greater curvature plication (Gastric Imbrication)
- LAP-BAND when BMI is 30 to 35 with or without comorbid conditions
- Endoscopic Suture Revisions post bariatric surgery
Health Net, Inc. considers any of the following procedures not medically necessary at this time, due to potential complications and a lack of positive outcomes:
- Biliopancreatic diversion (BPD) procedure (also known as the Scopinaro procedure)
- Jejunoileal bypass (jejuno-colic bypass)
- Gastric pacing
- Gastric wrapping
SECTION SUMMARY:
- General Appeal Instructions
- Appeal Details Specific to Health Net
If Health Net denies your weight loss surgery claim and you think it should be covered, consider filing an appeal.
Our Health Insurance Appeals page will get you started, then head over to the Disputes & Appeals page for Health Net to learn how to proceed.
SECTION SUMMARY:
- Ask for a free insurance check or cost quote
- Attend a free seminar or webinar
- Schedule a phone or in-person consultation (both often free)
Search the weight loss surgeon directory below to ask a surgeon about a free insurance check by country and region:
