WPS Health Insurance Weight Loss Surgery – How to Avoid a Denial

Your WPS Health Insurance 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 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 WPS Health Insurance for bariatric surgery in the United States, you must meet the following criteria:

  1. Be Age 18 or older
  2. Diagnosis of Morbid obesity, defined as
  3. Or

    • BMI 35 – 39.9 AND one of the following
      • Coronary artery disease
      • Diabetes Mellitus
      • Hypertension
      • Sleep apnea
      • Pseudotumor cerebri
      • Degenerative joint disease
      • Metabolic syndrome
      • Gastro-Esophageal Reflux Disease (GERD)
      • Obesity hypoventilation

    Use this BMI Calculator to check your body mass index…

  4. Documentation of complete history and physical (including evaluation and treatment of obesity related comorbidities, BMI history, history of previous weight loss attempts, and evaluation of surgical risks. Cardiac, pulmonary, endocrine, and GI evaluation is obtained as indicated
  5. Nutritional evaluation: (by a Registered Dietician) that includes all of the following:
    • Minimum of three visits
    • Initial clinical nutrition evaluation (may include micronutrients)
    • Instruction for post-surgery diet
    • Documentation that there is a reasonable expectation based on the evaluation and adherence to the pre-surgical program, that the member will be able to comply with the post-surgical diet plan
  6. Documentation of a psychological evaluation that assesses appropriateness for surgery, issues related to addiction, and ability to comply with the pre and postoperative program. If the member is receiving treatment for an active behavioral health disorder, clearance from the treating provider is required with documentation that the patient’s psychiatric illness has been optimally treated
  7. Documentation that, within the past 12 months, there has been at least six months (three consecutive) of participation in a professionally supervised multidisciplinary weight loss program. Documentation must consist of actual progress notes for the dates of participation in the program. This documentation must include weight data as well as documentation that diet, exercise, and behavior modification were addressed. Participation which is summarized in the form of a letter is not acceptable. Appropriate documentation is:
    • Dated progress notes from one of the professionals (physician, dietician, or weight-loss professional) supervising diet, exercise, and behavior modification at least once every four to eight weeks during the six month period, with clear evidence that weight reduction management was the primary service provided to the patient on that date
  8. Surgery must be performed by a credentialed bariatric surgeon

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.

WPS Health Insurance 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.

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

Following are a list of WPS Health Insurance 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.

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03.

Covered Weight Loss Procedures

SECTION SUMMARY:

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

Please see below for the procedures WPS Health Insurance 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 WPS Health Insurance:

04.

Appealing a Denial

SECTION SUMMARY:

  • General Appeal Instructions
  • Appeal Details Specific to WPS Health Insurance

If WPS Health Insurance 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 WPS Health Insurance 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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* 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