Bariatric Surgery: Important Insurance Insights

The following are very basic insurance insights about bariatric surgery. Please note that each employer may purchase a different plan and the information below may not apply. Please call your insurance plan or employer benefits department for the most current and accurate information.

• Most PPO or indemnity insurers such as WPS, BCBS, CIGNA, Humana, Aetna and Anthem typically require a six-month physician supervised diet within the last year or two, 3-5 years of medical history that includes diagnosis of obesity and documentation of any previous weight loss attempts and exercise programs. Sometimes structured programs such as Weight Watchers or Jenny Craig are acceptable. Depending on your insurance plan, the supervised diet can be done with your primary care provider or a registered nutritionist. Along with body mass index (BMI) documentation requirements, documentation of obesity related medical conditions may be required. Please contact your benefits plan for specific information.
• Medicare, a national government plan, offers bariatric surgery to their beneficiaries if they have a BMI greater than 40 or if BMI is 35-39 must have at least one severe medical condition such as diabetes, hypertension, obstructive sleep apnea or cardiac disease. One can only have surgery at a recognized Center of Excellence. Documentation of a medically supervised diet is required. Medicare pays 80 percent of charges.
• Medicaid/Badgercare, Wisconsin state government aid, offers both the gastric bypass and the adjustable gastric band procedures to those with a BMI greater than 40 with at least one severe medical condition such as diabetes, hypertension, obstructive sleep apnea or cardiac disease. Medicaid/Badgercare requires completion of a six-consecutive month, physician-supervised diet within the last 12 months. There must be documentation by your physician and nutritionist for six months in a row as well as a severe medical condition such as uncontrolled diabetes, hypertension or sleep apnea before an appointment can be made. Please refer to the benefits plan for more details.
• Currently the local HMOs exclude (do not cover) bariatric surgery or weight loss surgery.