Insurance for Gastric Sleeve Surgery
The coverage of insurance for gastric sleeve surgery will usually differ from state to state, and it will also vary depending on the insurance provider that you choose, but you should know that it there is a possibility that you can use insurance for gastric sleeve surgery.
At present, there are a number of companies that offer insurance for gastric sleeve surgery, among other bariatric procedures, although you will need to qualify for any coverage that these companies can offer you.
Some of these insurers are: Cigna, Aetna, Health Net, Emblem Health, Health Care Service Corp., Priority Health, Blue Cross-Blue Shield, and United Healthcare, which all offer you the option to provide insurance for gastric sleeve surgery to those individuals that are qualified.
Click here to read more about your options for Financing Bariatric Surgery.
Insurance For Gastric Sleeve Surgery – What Is Covered?
The insurance for gastric sleeve surgery usually covers a similar scope of items as other bariatric procedures. Things such as the cost for the hospital facility fees, anesthesia fees, as well as the surgeon’s professional fee are typically covered. A number of insurers may cover the cost of the entire bill, while some others may only cover 80% of what may be considered as “usual and customary fees” for the procedure.
The term ‘usual’ specifies the standard rate that is charged for the work by the provider performing the treatment, and the term ‘customary’ is the benchmark rate of the providers in neighboring areas. The usual and the customary price may be different for each circumstance and will be set by the company providing the insurance for gastric sleeve surgery. There are several insurance companies and/or employers that require a co-pay, meaning you will need to cover some of the cost out of your own pocket. The co-pay amount may start from a small fee like $500, or the co-pay amount can be up to $5,000.
There are items that insurance for gastric sleeve surgery will not cover, such as cosmetic procedures following the procedure. Take for example the body contouring procedure, insurance providers typically will not cover the removal of the excess skin since it is not medically necessary. Cosmetic procedures such as an arm lift, liposuction, a corset trunkplasty or any type of plastic surgery procedure that you may want to undergo following your weight loss will not be covered by insurance for gastric sleeve surgery. The reason is that the insurance for gastric sleeve surgery can really be used only for the gastric sleeve procedure, the medically necessary treatment, and not any elective follow-up procedures. The good news about the gastric sleeve is that you do not have a drastic loss of weight, it is a gradual loss which allows your skin to tighten and adjust as the weight comes off. This usually means that no cosmetic surgery will be required afterwards.
Insurance for gastric sleeve surgery may include programs or other things that are essential to a successful weight loss, such as the cost for support groups, daily exercise programs and nutrition counseling, but again, this will vary with each insurer. There are some people who may not be able to lose an adequate amount of weight with only a gastric sleeve procedure, they may need another procedure like the duodenal switch or the gastric bypass. These secondary surgeries may be covered, or may not be covered by the insurance as they are a part of what they call a ‘staged approach’ to losing weight. The best advice would be to speak with your bariatric surgeon and your insurance provider before committing to anything.
Insurance For Gastric Sleeve Surgery – Do I Qualify?
BMI of 40 or Higher
Some insurance carriers may cover for the cost of the gastric sleeve if you meet the specified criteria, which may differ with each insurance provider. A lot of insurance companies and/or employers that offer insurance for gastric sleeve surgery may require you have a BMI that is 40 or higher to qualify for the sleeve surgery. A BMI of 40 and above is equivalent to being 80 lbs overweight for women and 100 lbs overweight for men.
BMI of 35 plus Medical Issues
You may also qualify for insurance for gastric sleeve surgery if your BMI is 35 AND if you suffer from any major medical problems that are related to your weight, such as sleep apnea, type 2 diabetes, and heart disease to name a few.
Insurance For Gastric Sleeve Surgery – The Providers
It is very common that different providers cover different things when it comes to insurance for gastric sleeve surgery. Take the case of the United Healthcare; this company will provide insurance for gastric sleeve surgery for those individuals who have a BMI of 40 or more, or a BMI of 35 to 39.9 with at least 1 obesity related illness.
Some companies will not permit patients whose BMI is less than 40 to qualify for insurance for gastric sleeve surgery, period, for the reason that the company has not restructured their requirements so that it includes the gastric sleeve as a separate procedure for bariatric treatment. Blue Cross-Blue Shield Arkansas for example necessitates a BMI that is 60 or greater for gastric sleeve coverage. If the person suffers from severe lung and heart problems that are associated with obesity, they may have a lower BMI prerequisite to qualify for insurance for gastric sleeve surgery.
Some providers do not offer insurance for gastric sleeve surgery at all, so it is always a good idea to investigate the available options to you first so there are no surprises down the road.
Government Insurance for Gastric Sleeve Surgery
At present, Medicare, a U.S government health plan that caters for people ages 65 and above, does not cover the cost for the sleeve gastrectomy, but at present they are re-evaluating the available data which may lead to a policy change. There is also Medicaid, a federal government health care plan, which is for low income families and individuals. This kind of program is being governed by each state, but unfortunately there are only a few states that have Medicaid programs that offer Medicaid insurance for gastric sleeve surgery.
Insurance For Gastric Sleeve Surgery – Action Points
Letter Of Medical Necessity
Many insurance companies will require that you provide a ‘letter of medical necessity’ from the surgeon before they will qualify you for insurance for gastric sleeve surgery, and cover the costs. You will have to get this letter from your bariatric surgeon. The content of the letter should include info about your current physical condition, your medical history, your height, weight and BMI. It should also include a detailed account on the obesity health condition and the current medications will also be required on the letter.
Documented History of Weight Loss Attempts
To qualify for insurance for gastric sleeve surgery, many insurers will require that you have at least tried to lose weight through other means, and that those attempts have been documented by a medical professional. If you have dieted, exercised and tried other ways to lose the excess weight, but none were documented, you will probably have to try to lose the weight and have your attempt documented this time around. Most insurers require an attempt of at least 6 continuous months, while other providers require a 12 month attempt in order to be considered for insurance for gastric sleeve surgery.
Basically, you will need to present past and present records of all treatments of the obesity related problems plus the detailed record of all the weight loss efforts to show that you have tried and failed to lose the weight. This will help your case, making it more evident that surgery is your only option, and that insurance for gastric sleeve surgery should cover the costs due to the necessity. Since the coverage does vary from provider to provider and from state to state, it would be best to investigate all your options first.
The first step would be to speak with the bariatric surgeon, they will know more about which companies provide insurance for gastric sleeve surgery, and which do not. They can also provide information on the qualifications, and what you need to do to get coverage. If you are considering a gastric sleeve procedure, it is best that you have all the facts first. It is better to know beforehand, rather than prepare for the procedure and find out that you will not be covered. If you have any type of health coverage through work, speak with your HR department and find out all you can, or better yet, speak directly with the insurance provider. Find out if they cover the gastric sleeve procedure, and if so, what are the qualifications to be covered by insurance for gastric sleeve surgery.