Your QualChoice – Federal Employees Health Benefits 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
- 35+ Body Mass Index (BMI)
- Documentation of failed diet attempt
- 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 QualChoice – Federal Employees Health Benefits for bariatric surgery in the United States, you must meet the following criteria:
- Be between age 18 and 64
- Diagnosis of Morbid obesity, defined as
- a Body Mass Index (BMI) greater than 40
- BMI 35 – 39.9 AND one of the following
- Coronary heart disease
- Diabetes mellitus
- Clinically significant obstructive sleep apnea
- Medically refractory hypertension
Use this BMI Calculator to check your body mass index…
- Member has participated in clinically supervised nutrition and exercise program (including dietician consultation, low calorie diet, exercise counseling, and behavioral modification, and pharmacologic therapy, if appropriate), documented in the medical record. This clinically-supervised nutrition and exercise program must meet all of the following criteria:
- Nutrition and exercise program must be supervised and monitored in a clinical setting and working in cooperation with dieticians and/or nutritionists
- Nutrition and exercise program(s) must be for a cumulative total of 12 months or longer in duration and occur within 2 years prior to surgery
- Proximate to the time of surgery, member must participate in organized multidisciplinary surgical preparatory regimen of at least three months duration in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member’s ability to comply with post-operative medical care and dietary restrictions.
Repeat bariatric surgery is considered medically necessary when the initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria), and when either of the following medical necessity criteria are met:
- Conversion to a RYGB may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure
- Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the 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.
QualChoice – Federal Employees Health Benefits Contact Information and Full Medical Policy on Bariatric Surgery
- 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.
QualChoice – Federal Employees Health Benefits does cover weight loss surgery, but your specific policy must include it in order for you get it covered.
Following are a list of QualChoice – Federal Employees Health Benefits 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
- Duodenal Switch
- Vertical Banded Gastroplasty
Please see below for the procedures QualChoice – Federal Employees Health Benefits 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 QualChoice – Federal Employees Health Benefits:
Procedures That Are NOT Covered
The following procedures are NOT covered by QualChoice – Federal Employees Health Benefits:
- General Appeal Instructions
- Appeal Details Specific to QualChoice - Federal Employees Health Benefits
If QualChoice – Federal Employees Health Benefits 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: