Bariatric Surgery Insurance
( Incl. Lap Band Insurance, Gastric Bypass , DS & Gastric Sleeve Insurance )

This page is a complete guide to bariatric surgery insurance in the United States.

Australia Insurance - Click here

Canada Insurance - Click here

Most insurance companies in the United States include bariatric surgery as an option in their plans. So why can it be so difficult to get them to pay?

This page will help you figure out…

  • Whether bariatric surgery is covered under your plan
  • How to get the surgery approved if it is
  • If weight loss surgery is not covered, how you may be able to get it added to your plan or find a plan that covers it

We cover several insurance-related topics on this page, but you only need to worry about the sections that apply to you. First, click on the following link that describes the kind of insurance that you have or are looking for…

If appropriate, the section title (link) that you click on above will direct you to the following additional information…

Will Surgery Complications Be Covered?

If your insurance does not cover weight loss surgery, in all likelihood it won’t cover complications resulting from surgery. However, emergency treatment will always be covered, regardless of the cause.

Individual, Family or Small Business Insurance (50 employees or Less)

Affordable Care Act (Obamacare) & Weight Loss Surgery

It is up to your state to determine whether or not your state's exchange will require bariatric surgery to be covered.

For now, plans sold on the insurance exchanges will include benefits that were covered by the most popular small group health plans before 2014. While popular small group plans in many states (along with 2/3 of large employers and Medicare) currently cover bariatric surgery, small group plans in many states do not currently cover it.

Click here for more information.

While many individual, family and small business insurance policies still exclude bariatric surgery, some insurance companies are starting to come around.

For example, we found this in the contracts of Blue Shield of California's Balance Plans:

"As with all Blue Shield PPO plans, the Balance Plans provide coverage for Bariatric surgery if it is authorized by a preferred provider who can verify that the procedure is medically necessary to control obesity. Hospital stays at medical facilities that are not on the Blue Shield preferred list are limited to a maximum benefit of $250 per day."

There are various Blue Cross and Blue Shield organizations around the country that operate very differently from each other (and are sometimes combined), and the above quote applies to Blue Shield of California's plans.

Regardless, if you already have individual, family or small business coverage, check your plan documents and call your insurance company, broker/agent or human resources department to find out if bariatric surgery is covered.

If you confirm that weight loss surgery is not covered and there are none available in your area that will, you still have 8 options for financing bariatric surgery to make treatment more affordable and to potentially reduce your overall expenses.

If you have short term disability insurance through your employer, also see the Disability Insurance section below. You may be able to receive portion of your monthly salary while you’re having and recovering from surgery.

If you determine that surgery is covered, jump down to General Bariatric Surgery Insurance information.

Back to top of Insurance Bariatric Surgery ( Lap Band Insurance, Gastric Bypass Surgery Insurance, DS & Gastric Sleeve Surgery Insurance )

Large Employer-Provided (50+ Employees) Bariatric Surgery insurance
( VBG, DS, Gastric Bypass and lap band insurance )

If you get health insurance through your employer (and your employer has 50 or more employees), there are a few ways to determine whether bariatric surgery is covered…

  • Review your plan documents on your insurance company’s web site (you’ll need to register and sign in with a username and password) or in the booklet that you should have received during open enrollment.
  • Call your insurance company directly using the phone number on the back of your insurance card.
  • Contact your Human Resources department.

If your plan doesn’t cover weight loss surgery, you may be able to get it covered if you are willing to put in the extra work.

We'll get into your next steps in a moment, but first...

Could the state you live in affect
whether bariatric surgery is covered?

Before you get started, understand that insurers in some states are encouraged by state law to include bariatric surgery (Georgia, Indiana, Maryland, New Hampshire and Virginia, with several other states on the cusp including Louisiana, Ohio, South Carolina and Tennessee among others).

Unfortunately, even if your state has laws in place regarding bariatric surgery and insurance, insurers are not forced to provide coverage for weight loss surgery. The laws simply recommend that the surgery be covered based on the level of medical necessity, and they permit insurers to charge more if they do include it.

In addition, states sometimes exempt the individual or small business insurance companies from complying with the recommendations, or they may only apply legislation to insurance companies that are headquartered in the state.1

Talk with your insurance company or a good broker to find out if state mandates apply to your plan. 

Is Your Surgeon
Out of Network?

If you choose a bariatric surgeon that is not currently included in your insurance company’s network, you may be able to get them added.

Contact your insurance company and tell them that your doctor is not in their network and that you would like to get them added. They will let you know the steps necessary to get the surgeon credentialed, approved and added.

Expeditious insurance companies can usually complete this process within 2 to 3 months.  If you have trouble handling this directly, contact your Human Resources department for assistance.

Assuming your plan covers bariatric surgery, the below chart includes...

  • The surgeries covered by the most popular group health insurance companies
  • Links to search for your doctor in your carrier’s provider database (your surgeon and doctor have to be in your insurance company’s network in order to be covered)
  • Links to more information about your carrier’s bariatric surgery policies

After reviewing the chart, jump down to General Bariatric Surgery Insurance information.

If you don’t see your insurance carrier in the chart, take out your insurance card.  Your insurance company's web site should be listed, along with a phone number so you can call them directly.

If bariatric surgery insurance is not included in your employer’s plan, click here to find out how you may be able to get it covered.

Insurer Bariatric surgery procedures allowed IF your policy includes bariatric surgery coverage* Link to bariatric doctor search Link to company- specific bariatric surgery info
*Important – the above is a general summary and is subject to change.  You must review your specific policy for bariatric surgery insurance requirements (VBG, DS, gastric bypass, gastric sleeve or lap band insurance requirements) and coverage options.
United Healthcare (UHC)
UHC doctor search UHC details
Wellpoint/Anthem Blue Cross/Blue Shield Anthem owns many different Blue Cross and/or Blue Shield organizations and each may have different policies regarding bariatric surgery.  To figure out your insurance company’s details, click here.

Once on Anthem’s site, choose your state in the “To enter site, click here” drop down box towards the top of the page.  Once on your page (you may be required to enter a username and password), go to the “Members” section and type “bariatric surgery” in the search box.
Aetna
Aetna doctor search Aetna details
Humana Humana’s web sites do not provide bariatric surgery-specific information without logging in as a member. Click here to log in.
CIGNA
CIGNA doctor search CIGNA details
Health Net
Health Net doctor search Health Net details
Coventry Health Care Coventry has different policies by state, so you’ll need to go to their web site, choose your state, then log into see your options.

Assuming your plan covers bariatric surgery and you are finished reviewing the chart, jump down to General Bariatric Surgery Insurance information.

If you employer's plan does not currently cover bariatric surgery, you may be able to convince your employer to add it to your plan.

Your first step is to go to Human Resources (HR) and present your case. The only way HR is going to get senior management to add bariatric surgery is if HR can present a compelling business reason to do so.

The trick to presenting a compelling business case to HR is to take all emotions out of the discussion. You should focus strictly on how adding bariatric surgery is a good business decision and will improve your company’s bottom line (how much money they make).

We have good news…

In addition to providing you and others with a benefit that will improve your health and extend your life, adding bariatric surgery to your plan is an extremely good business decision.

To help your Human Resources department understand why, either:

  1. Refer your HR representative to the following section (you can send them the direct link to this section by copying and pasting the following internet address (URL) into an email: lap-band-insurance.html#business_reasons

    -or-
  2. Print and present the following section along with this page (click link to open pdf document) on your own.
Back to top of Insurance Bariatric Surgery ( Lap Band Insurance, Gastric Bypass Surgery Insurance, DS & Gastric Sleeve Surgery Insurance )

Business reasons to add bariatric surgery to your company’s health insurance plan

Unhappy with your current broker or consultant? If your company has more than 500 employees, contact us. We are familiar with several highly recommended consultants across the country that we'd be happy to put you in touch with.

For no extra charge, a good employee benefits broker or consultant should be able to do all of the legwork (including presenting the results to Finance) surrounding bariatric surgery and determine how adding it to your plan would impact your company.

In most cases, you will find that adding weight loss surgery will reduce your overall health care costs and increase the productivity of your morbidly obese employees.

Leading the Charge

Hawaii Pacific Health (HPH) has been one of the first employers in the country to cover weight loss surgery under their wellness program, and their program fully reimburses qualified employees for all expenses.

Gail Lerch, HPH's executive vice president of human resources, made the recommendation to add bariatric surgery because she felt that not to add it "will cost us far more in medications and lost attendance for our employees, who we are helping to make changes in their life."

Click here for the full story.

Following are the research-supported reasons to add bariatric surgery to your plan:

1. Direct Financial Benefit

According to the American Journal of Managed Care (AJMC), an investment in bariatric surgery will break even within 2 years for laparoscopic surgery and within 4 years for open surgery (about 80% of bariatric procedures are laparoscopic).

Click here to see how The HR Capitalist views this data.

In addition, most major insurance companies have determined that bariatric surgery eliminates or improves obesity health problems to the extent that they have agreed to offer coverage as an option. And several states actually require that it be included. Table 2 of the AJMC study shows that following 13 months after surgery, patients saved over $900 per month compared to those who did not receive it.

A Duke University Medical Center study also found that obese workers file twice as many workers compensation claims and have 7 times higher medical costs than non-obese workers.

2. Indirect Financial Benefit

The same Duke study referenced above found that obese employees lose 13 more days on average when they suffer a work injury.

A Journal of Occupational and Environmental Medicine (JOEM) study also concluded that moderately to extremely obese workers experienced a 4.2% health-related loss in productivity compared to 3.02% for everyone else. This 1.18% difference equated to $506 per worker annually.

In addition to confirming health care cost differences, a study posted by the National Center for Biotechnology Information (NCBI) found that severe and morbidly obese workers had 57% more annual sick days than their non-obese counterparts.

3. Legal Considerations

There are situations where you may be legally required to pay for weight loss surgery. In Boston’s Gourmet Pizza v. Adam Childers, for example, an Indiana court ruled that the employer must pay for bariatric surgery as a precursor to treating a work-related back injury. Adding it to your health plan now could prevent future legal issues and the added expense of paying for surgery on a “one-off” basis.

4. Is your health insurance plan self-funded?

If so, the long-term cost savings of bariatric surgery will be much more apparent. If you are unsuccessful in getting surgery added to your plan, do your company’s policies allow the use of your “ex-gratia” plan provision? In other words, could your company agree to pay for the surgery on a one-off basis outside of the scope of your stop loss agreements for the employee who asked that you consider adding bariatric surgery?

We have prepared a series of questions and a sample scenario that will help you or your broker/consultant determine whether bariatric surgery is a good business decision for your company.  Click here to open the pdf file.

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General Bariatric Insurance Information
( VBG, DS, Gastric Bypass, Gastric Sleeve and lap band insurance )

If bariatric surgery is covered under your plan and there is so much research supporting the long term health benefits and cost savings, why is it so difficult to get insurance companies to pay?

YOUR Weight Loss Journey

Help visitors like you by sharing your advice related to this page or other topics...

The problem is that surgery costs a lot of money, and insurance companies make money by collecting more than they spend.

Even though bariatric surgery is a good investment over the long run (the money will be made back in 2 to 4 years), insurance companies are worried that you won’t pay premium long enough for them to earn it back. In other words, you’ll switch insurance companies earlier than 2 to 4 years.

If you’ve determined that bariatric surgery is covered by your plan, there are several things you should keep in mind before moving forward…

  1. Call your insurance company to make sure that the surgery will not be considered a pre-existing condition – if it is, weight loss surgery won’t be covered. In general, if you receive coverage through your employer, pre-existing conditions limitations will not apply as long as you enroll or enrolled in your plan during open enrollment or after a qualifying event (marriage, new employer, birth of a child, divorce, etc.).
  2. Even if your plan provides bariatric surgery insurance ( VBG, DS, gastric bypass or lap band insurance ), you could still have substantial out of pocket costs.

    According to a survey by creditcards.com, about 50% of people with insurance don’t know their deductible. Make sure you read and understand your specific benefit plan to understand what your out of pocket liability will be. If your deductible and coinsurance will make surgery difficult to afford, see our Financing Bariatric Surgery page for ideas on how to spread the payments out over time.

    For example, your surgeon may allow you to set up an interest-free payment plan for your share of the costs, and if not you may be able to receive financing for your out of pocket costs from banks or other financial institutions.
  3. Your insurance company will require you to choose a provider (surgeon and hospital) within their network. Depending on your plan and insurance company, you may also be required to choose a surgeon within a certain distance of your home or work zip code.

    Depending on where you live, you may not be able to find an in-network provider that both satisfies your requirements AND meets the insurance company's distance requirements. If this is the case, contact your insurance company.

    If you have reasonable doctor-supported demands (i.e. want laparoscopic surgery instead of open surgery or prefer one surgery over another), your insurance company may allow you to choose an non-network provider.
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Bariatric Surgery Insurance Approval
( VBG, DS, Gastric Bypass, Gastric Sleeve and lap band insurance )

Patient Experiences

Don't forget to check the last section of this page for actual patient experiences, and please pay this page's free information forward by sharing your experiences as well!

If bariatric surgery is included in your plan, there will most likely be several conditions that need to be met before surgery will be approved…

  1. The bariatric doctors and bariatric weight loss center must be in your insurance company’s network. Your insurance company may also require that you receive a referral to a bariatric surgeon from your Primary Care Physician. As mentioned above, if your surgeon of choice is not in your insurance company’s network, call your insurance company to learn how you can get your surgeon added.
  2. Based on the National Institutes of Health’s (NIH) recommendation, insurance companies usually require that you are at least 18 years of age or have reached full growth (as determined by an X-Ray to make sure that your growth plates have fused) AND have evidence that you have a:
    • BMI (body mass index) greater than or equal to 40, OR
    • BMI (body mass index) between 35 and 39.9 with at least one “clinically significant comorbidity.”  (See our BMI Formula page for more about body mass index.)
  3. Show that you have participated in an approved clinically supervised weight management program for a specific period of time. Each insurance carrier will have different criteria for what they consider “approved”.
  4. A recommendation of surgery (called a “Letter of Medical Necessity” - see the box below for more information) from a bariatric surgeon, including a description of the proposed procedures.
  5. A recommendation from a doctor other than your surgeon, including a medical clearance for bariatric surgery.
  6. Clearance for surgery from a mental health physician (usually part of a good bariatric surgeon’s team).
  7. A nutritional evaluation by a doctor or registered dietitian (also usually part of a good surgeon’s team).

What to Include in Your Letter of Medical Necessity

Your doctor should have their own template, but request a copy for your review before the letter is sent to your insurance company. This may be your only real shot at getting surgery approved! Following is commonly included in the letter…

  • Your height, weight history, and body mass index (BMI) (the longer you can show that you’ve been morbidly obese the more likely you will be to get an approval).
  • A description of your obesity health issues and how they impact your life. Your surgeon’s letter should include information about your specific health problems and research that supports weight loss surgery as a solution.
  • Previous weight loss attempts, both medically supervised and non-medically supervised.

The more supporting documentation from credible sources that you can include with the letter the better, including gym membership or personal trainer receipts, receipts from other diet programs, history of medications and doctors visits for your obesity-related health conditions and letters from other doctors, specialists or therapists.

It may also help to include a letter from you explaining the difficulties you face every day due to your weight, such as trouble sleeping, personal hygiene, mental health issues from obesity discrimination, physical obesity health problems, etc. Letters from other professionals (psychologist, physical trainer, orthopedist, nutritionist) confirming that you have been obese and the mental and physical health problems they have observed as a result are also very helpful.

In addition, click the following links, print the studies and include them with your response…

Get Insurance Help from Your Surgeon's Office

Did you know that your bariatric doctor's office may be able to help with your insurance approval process?

This is another reason to work with a surgeon’s office that has a lot of experience. In addition to being more practiced in the surgery itself, they also know what it takes to get your surgery approved. 

Many offices even have an insurance coordinator whose only job is to deal with insurance companies. They know how to write an effective recommendation letter and their track record with insurance companies will make the process go much more smoothly.

You will usually will receive a response from the insurance company within 30 days – if you still haven’t heard from them after 30 days have passed, follow up with a phone call or ask your surgeon’s office to call directly.

IF YOU GET THE SURGERY APPROVED – DON’T LET IT EXPIRE! Your insurance company should indicate the expiration date on your approval letter. If it’s not there, call them and get the expiration date in writing.

If your surgery is denied, it's time to start the appeals process.  See our Health Insurance Appeal Letter & the Appeals Process page for next steps.

If you have short term disability insurance through your employer, see the Disability Insurance section below – you may be able to receive a portion of your monthly salary while you’re having and recovering from surgery.

Back to top of Insurance Bariatric Surgery ( Lap Band Insurance, Gastric Bypass Surgery Insurance, DS & Gastric Sleeve Surgery Insurance )

Disability Insurance During and After Weight Loss Surgery

Disability insurance (DI) pays you a percentage of your monthly income if you are unable to work. Short term disability insurance (STD) most commonly pays 66 2/3% of your salary for the first 90 or 180 days of disability or sickness.

Unfortunately, it is usually only available through an employer, although you can continue coverage as an individual if you leave the company.

Just like health insurance, disability insurance includes pre-existing conditions limitations. In other words, insurance companies won’t let you buy coverage one month and go out on disability the next for something that you knew about before you signed up.

The best way to get around this for bariatric surgery is to enroll with your employer during the initial enrollment period (i.e. when you’re hired). You may not be allowed to enroll at any other time.

You must then remain enrolled for the entire “pre-existing conditions exclusionary period,” which usually lasts between 6 and 12 months. Call your insurance company, talk with HR or review your plan documents for details.

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Did insurance approve YOUR weight loss surgery?

If so, congratulations! Please share details, tips or advice to help others understand how you got your weight loss surgery approved, such as...

- Where you received coverage (i.e. work, individual policy, etc.)

- The insurance company you worked with

- How much your surgery cost and what insurance paid

- Your out of pocket costs and what you used to pay for them (i.e. savings, financing, etc.)

- What was your approval process?

- Were there any challenges, and how did you overcome them?

- Did you receive help?

- What about disability insurance?

Enter the a title for your experience (i.e. type of insurance, your key advice, words of encouragement, etc.)

How other visitors got their weight loss surgery insurance approved

Click below to see contributions from other visitors to this page...

Insurance Company Covers Bariatric Surgery But Denied Me 
My insurance company turned down paying for bariatric surgery, what do I need to do so I can have the surgery? Humana pays for bariatric surgery but …

Denied for sleeve trying for lap band, has anyone had any success in similar situation? 
I found out last week that I was denied for the gastric surgery, not just the gastric sleeve. I went to Sibley Hospital in DC and paid $600 for their program. …

Click here to write your own.

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References

  1. Vanek VW. State laws on insurance coverage for bariatric surgery: help or a hindrance? American Society for Bariatric Surgery. May 2005. doi:10.1016/j.soard.2005.05.001.

[Last editorial review/modification of this page: 10/9/2013]

Disclaimer: The information contained in this web site is provided for general informational purposes only. It is not intended as nor should be relied upon as medical advice. Rather, it is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her existing physician(s). Before you use any of the information provided in the site, you should seek the advice of a qualified medical, dietary, fitness or other appropriate professional. Read More