Your Priority Health 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
- 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 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 Priority Health for bariatric surgery in the United States, you must meet the following criteria:
- Over 18 years of age and the surgery must be performed by a surgeon who is a regular member in good standing of the American Society for Metabolic and Bariatric Surgery (ASMBS)
- Diagnosis of Morbid obesity, defined as
- a Body Mass Index (BMI) greater than 50 with no co-morbidity or participation in medical weight management program required
- a Body Mass Index (BMI) greater than 40, a co-morbidity is not required, however, participation in medical weight management program is
- a BMI 35 – 39.9 AND one of the following
- Symptomatic sleep apnea requiring treatment
- Significant cardiac disease (e.g. ASHD, RVH or LVH)
- Hypertension on one or more medications
- Hyperlipidemia on therapy
- Diabetes with HgbA1 C greater than 7.0 on one or more medications or insulin
Use this BMI Calculator to check your body mass index…
- Complete medical evaluation by PCP or other physician
- Evidence that all other alternatives have been discussed with and offered to patient, and that all reasonable non – surgical options have been attempted
- Documentation of active participation in and compliance with a medical weight management program, when applicable, provided by a credentialed physician with a declared interest in the management of obesity, the member’s primary care physician (PCP) or other managing physician as outlined in the Medical Management of Obesity policy. The medical weight management program must include all of the following:
- Documentation of active participation and compliance with a medical weight management program for a minimum continuous duration of * 6 months with at least 6 office visits including both a diet and exercise component and in which the obesity and weight – related conditions (i.e. diabetes, hypertension and hyperlipidemia) are being addressed
- NOTE: this only applies for individuals with a body mass index below 50
- Priority Health Medicaid requires compliance with a medical weight management for a minimum continuous duration of 12 months and at least 12 office visits
- Thorough progress notes and records that include the following regarding the obesity problem at each visit:
- An actual measured weight and calculated BMI
- The patient’s history
- An actual measured weight and calculated BMI
- The physical findings
- The physician’s assessment
- The physician’s treatment recommendation(s)/plan(s)
- The medical weight management program must be completed within two years of the request for surgery. All documentation in #3 above should be submitted with the Bariatric Surgery prior authorization form. The BMI recorded on the prior authorization form should be based upon measurement of height and weight within one month of requesting the evaluation
Some of the Reasons for Denial
Even if you meet the 2 requirements outlined in this section, you will likely NOT be approved if any of the following apply to you:
- Severe psychopathology
- Medical conditions that make patient a prohibitive risk
- Any disease (e.g. cancer, uremia, liver failure), associated with a likelihood of survival less than 1 year
- Substance abuse including alcohol and other drugs of abuse. Six months of abstinence prior to surgery is required to meet this criterion
- Tobacco use. At least one month of abstinence prior to surgery is required to meet this criterion. The surgeon must require at least one month of tobacco abstinence prior to the surgical procedure
Coverage is limited to one bariatric surgery per lifetime regardless of insurance carrier or other means of payment at the time of surgery, unless Medically/Clinically Necessary to correct or reverse complications from a previous bariatric procedure.
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.
Priority Health Contact Information and Full Medical Policy on Bariatric Surgery
- By Phone: 800.942.0954
- Contact Priority Health
- Full Bariatric Surgery Medical Policy for Priority Health
- Coverage Through Your Employer
- Individual & Family Plans
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.
Priority 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 Priority Health 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)
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Rhode Island
- South Dakota
- West Virginia
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.
- Gastric Sleeve
- Gastric Bypass
- Duodenal Switch
Please see below for the procedures Priority 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 Priority Health:
Procedures That Are NOT Covered
The following procedures are NOT covered by Priority Health:
- General Appeal Instructions
- Appeal Details Specific to Priority Health
If Priority Health denies your weight loss surgery claim and you think it should be covered, consider filing an appeal.
- 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: