Moda Health Weight Loss Surgery – How to Avoid a Denial

Your Moda Health weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.

To request a free insurance check, click here to contact a local surgeon. Alternatively, use the tool below to find out if you have 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

  1. Coverage Requirements
  2. Coverage Plans
  3. Covered Procedures
  4. Appealing a Denial
  5. Find a Weight Loss Surgeon
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01.

Coverage Requirements

SECTION SUMMARY:

  • 35+ Body Mass Index (BMI)
  • Documentation of failed diet attempts
  • Psychological evaluation

READ THIS FIRST

Even if your insurance company has a policy about bariatric surgery coverage, that does not mean that your 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 policiy 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 Moda Health for bariatric surgery in the United States, you must meet the following criteria:

  1. The patient is 18 years of age or older and has reached full skeletal maturity
  2. Diagnosis of Morbid obesity, defined as
  3. Or

    • BMI 35 – 39.9 AND one of the following
      • Type II diabetes mellitus
      • Medically refractory hypertension
      • Life threatening cardiac or pulmonary conditions
      • Debilitating joint disease in weight bearing joints

    Use this BMI Calculator to check your body mass index…

  4. Completion of the following:
    • Documentation of 6 consecutive months of active participation in a medically supervised weight reduction program which has failed despite documented patient compliance. Participation must have occurred within the last 2 years and program components must include diet therapy, physical activity and behavioral modification
    • Medical consultation prior to surgery to establish the patient’s commitment and ability to tolerate the operative trauma and risks associated with surgical intervention
    • Psychological consultation/evaluation with clearance for the procedures and likelihood of compliance with a post-operative program
    • The patient has no specifically correctable cause for obesity, such as an endocrine disorder
    • Weight loss surgery is not an exclusion from the group contract.
    • The requested procedure does NOT include intragastric balloon (IGB) (i.e. ReShape, Orbera, Spatz, Elipse). This procedure is considered investigational as the safety and effectiveness over standard bariatric procedures has not been demonstrated in randomized peer-reviewed clinical studies.

Reoperation and Surgical Revision

  1. Surgical revision, reversal, or removal is not covered. Medical and surgical complications may be covered if determined to be medically necessary to stabilize even if the original surgery was not a covered benefit.
  2. Revision of a previous bariatric surgical procedure or conversion to another bariatric surgical procedure due to inadequate weight loss may be considered when coverage for bariatric surgery is available under the patient’s current health plan and the above criteria are met.

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.

Moda Health Contact Information and Full Medical Policy on Bariatric Surgery

02.

Coverage by Plan Type

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.

Moda Health does cover weight loss surgery, but your specific policy must include it in order for you get it covered.

Following are a list of Moda Health plan types and whether they cover bariatric surgery:

Moda Health 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:

Moda Health 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:

    • 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.

Moda Health Weight Loss Surgery for Medicare Plans

All Medicare plans are required to cover the following weight loss surgery procedures:

However, special Medicare-specific criteria apply. Click here to learn more about Medicare bariatric surgery coverage.

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03.

Covered Weight Loss Procedures

SECTION SUMMARY:

  • Gastric Sleeve
  • Gastric Bypass
  • Lap-Band
  • Duodenal Switch
  • Vertical Banded Gastroplasty

Please see below for the procedures Moda Health covers, might cover under certain circumstances, and those that are not covered under any circumstances:

Procedures That ARE Covered

Procedures That MIGHT BE Covered

The following procedures MIGHT BE covered by Moda Health:

Procedures That Are NOT Covered

The following procedures are NOT covered by Moda Health:

04.

Appealing a Denial

SECTION SUMMARY:

  • General Appeal Instructions
  • Appeal Details Specific to Moda Health

If Moda Health 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 Moda Health to learn how to proceed.

05.

Find A Top Weight Loss Surgeon

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:

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