Insurance vs. Self Pay

Criteria for bariatric surgery coverage by insurance company:

Insurance companies are frequently changing their coverage criteria and have multiple medical plans.  Please call directly to your insurer’s members service and confirm current requirements and eligibility for bariatric surgery coverage in your particular case.

Most frequently encountered requirements by insurance company:

AETNA:  NIH criteria, 5 years documented by a doctor history of obesity, consecutive 6-month (or two 3-month periods) supervised diet within 2 past years, evaluation by dietitian & psychologist.

Blue Cross/Blue Shield:  NIH criteria, supervised 6-month (or 3 months two times) diet within 2 past years, evaluation by dietitian & psychologist.

Blue Cross Federal:  NIH criteria, 3-6 months supervised diet, evaluation by dietitian & psychologist.

CIGNA:  NIH criteria, supervised 6-month diet within 2 past years, evaluation by dietitian & psychologist.

MAMSI/MDIPA/Optimum Choice:  NIH criteria, 5 year weight history some plans may require 6 months supervised diet), evaluation by dietitian & psychologist.

MAMSI/MDIPA/Optimum Choice Federal:  NIH criteria, supervised 6-month (or 3 month two times) within past 2 years, evaluation by dietitian and psychologist.

MEDICARE:  NIH criteria, supervised 6-month diet, evaluation by dietitian and psychologist, participation in preparation/conditioning program with surgeon for 3 months, co-morbid conditions include only hypertension untreatable with 2 or more medications, diabetes Type II, sleep apnea, severe arthritis requiring joint replacement, fatty liver; Weight loss of 10% and more before surgery makes patient ineligible for surgery; revisional procedures are not covered unless there is a complication of initial surgery.

UnitedHealthcare:  NIH criteria, 5 years documented by a doctor history of obesity, evaluation by dietitian and psychologist.
 

Can I self pay for my weight loss?

Our preference is for you to use your insurance to avoid the significant (up to 90% of total charges) hospital and other related costs.  At present, overall cost of gastric banding surgery is about $15,000, gastric bypass surgery – $20,000 and vertical sleeve gastrectomy – $ 17-18,000.  Most insurance companies do authorize bariatric surgery and we are prepared to work with you to obtain authorization and help you with the appeal process if needed.

Unfortunately, there are multiple exclusions in various insurance plans, restrictive covenants and conditions.  Some medical insurance plans, especially small businesses etc. completely exclude coverage for weight loss surgery.

If you need to self pay, please contact our office and an insurance specialist will advise you on available financing options which work similar to car loan financing and cover total costs of surgery.