Scott & White HP Weight Loss Surgery – How to Avoid a Denial

Your Scott & White Health Plan 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

  1. Coverage Requirements
  2. Coverage Plans
  3. Covered Procedures
  4. Appealing a Denial
  5. Find a Weight Loss Surgeon
Advertisement
Bariatric Surgery Source
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 Scott & White Health Plan for bariatric surgery in the United States, you must meet the following criteria:

  1. Diagnosis of Morbid obesity, defined as
  2. Or

    • BMI 35 – 39.9 AND one of the following
      • Type 2 diabetes
      • Refractory hypertension
      • Refractory hyperlipidemia in spite of diet and pharmacotherapy
      • Obesity induced cardiomyopathy
      • Clinically significant obstructive sleep apnea
      • Obesity related hypoventilation
      • Pseudotumor cerebri
      • Severe arthropathy of spine and/or weight bearing joints where obesity precludes appropriate surgical management
      • Hepatic steatosis without evidence of active inflammation

    Use this BMI Calculator to check your body mass index…

    More About Co-Morbid Conditions & BMI

    Though the high-risk co-morbid conditions listed in this section need not be immediately life-threatening for Medicare to cover bariatric surgery, the condition must not be trivial or easily controlled with non-invasive means (such as medication) and must be of suffici ent severity as to pose considerable short- or long-term risk to function and/or survival.

    Some benefit packages permit certain bariatric procedures at BMI greater than or equal to 30.

    Check your Explanation of Coverage or Summary Plan Document for coverage details.

  3. History of previous unsuccessful medical treatment for obesity as determined by meeting ALL of these criteria:
    1. The patient has been provided with knowledge and tools needed to achieve lifelong lifestyle changes, exhibits understanding of the needed changes and has demonstrated to clinicians involved in his or her care to be capable and willing to undergo the changes
    2. The patient has made a diligent effort to achieve healthy body weight with such efforts described in the medical record and certified by the operating surgeon
    3. The patient has failed to maintain a healthy weight despite adequate participation in a structured dietary program overseen by one of the following: Physician (MD or DO), Registered dietician (RD), Board certified specialist in pediatric nutrition (CSP), Board certified specialist in renal nutrition (CSR), Fellow of the American Dietetic Association (FADA)
  4. Pre-operative evaluation by a mental health professional (psychiatrist or psychologist) experienced in the evaluation and management of bari atric surgery candidates to exclude patients who are unable to personally provide informed consent, who are unable to comply with a reasonable pre- and postoperative regimen, or who have a significant risk of postoperative decompensation is recommended. The mental health professional, the surgeon and the patient should be in agreement that the patient is an appropriate candidate for the surgery

A patient undergoing bariatric surgery should undergo preoperative evaluation that is medically reasonable and necessary based upon his comorbid medical conditions and medical/surgical history. All underlying medical conditions that will likely impact or complicate the patient’s surgical and postoperative course must be adequately controlled before surgery.

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.

Contact Scott & White Health Plan 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.

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

Following are a list of Scott & White Health Plan 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:

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.

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.

Advertisement
Bariatric Surgery Source
03.

Covered Weight Loss Procedures

SECTION SUMMARY:

  • Gastric Sleeve
  • Gastric Bypass
  • Lap-Band
  • Duodenal Switch
  • Biliopancreatic Diversion Surgery (BPD)

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

Procedures That ARE Covered

Procedures That Are NOT Covered

The following procedures are NOT covered by Scott & White Health Plan:

04.

Appealing a Denial

SECTION SUMMARY:

  • General Appeal Instructions
  • Appeal Details Specific to Scott & White Health Plan

If Scott & White Health Plan 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 Scott & White Health Plan 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:

Advertisement
Bariatric Surgery Source

* Disclaimers: Content: The information contained in this website is provided for general information purposes and your specific results may vary depending on a variety of circumstances. 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. Advertising: Bariatric Surgery Source, LLC has entered into referral and advertising arrangements with certain medical practices, original equipment manufacturers, and financial companies under which we receive compensation (in the form of flat fees per qualifying action) when you click on links to our partners and/or submit information. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Read More