Bariatric Surgery Frequently Asked Questions (FAQs)
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UW Health Surgical Weight Management surgeons perform bariatric surgery procedures for people who want to lose weight safely and effectively.
The following is basic insurance information regarding bariatric surgery.
- Please note that coverage varies widely, each employer may purchase a different plan and the information below may not apply to your individual plan.
- Please call your insurer or employer's benefits department for the most current and accurate information regarding coverage and requirements of your plan.
- If your insurance or employer changes at any time, please let us know as soon as possible as this can impact your coverage.
What should I ask when I call my insurer?
We recommend that you call the customer service number on the back of your insurance card. Provide your ID number and ask if bariatric surgery is a covered benefit and what requirements for surgery are specified by your plan. Providing your specific ID will ensure that they check your specific employer policy. Once you have started with our program, we will ask for a copy of your insurance card and will call to verify your benefits and confirm that our facility is in network under your plan.
Will my insurance cover the costs associated with surgery?
Most PPO or indemnity insurers such as WPS, BlueCross BlueShield (BCBS), CIGNA, Humana, Aetna and Anthem typically require completion of a six-month medically supervised diet within the past one to two years. Depending on your insurance plan, the supervised diet may be done with your primary care provider or a registered dietitian; some structured programs (such as Weight Watchers or Jenny Craig) may also be acceptable.
Most insurers will require three to five years of medical history that includes a diagnosis of obesity and documentation of any previous weight loss attempts and exercise programs. Along with body mass index (BMI) documentation requirements, documentation of obesity-related medical conditions may be required.
What if my insurance does not cover surgery? Are self-pay packages offered?
The UW Health Surgical Weight Management Program offers self-pay packages for gastric bypass (Roux-en-Y) and sleeve gastrectomy procedures. Please contact our program to discuss whether this may be an option for you and for pricing information.
What coverage and requirements are specified by Medicaid/BadgerCare?
Medicaid/Badgercare offers the gastric bypass and sleeve gastrectomy procedures to beneficiaries with a BMI greater than 40 with at least one severe medical condition (such as uncontrolled diabetes, hypertension, heart disease or obstructive sleep apnea). Medicaid/Badgercare requires documentation of participation in a six-consecutive month, physician-supervised diet within the last 12 months. There must be documentation of at least one high-risk, lifelimiting co-morbid medical condition capable of producing a significant decrease in health status that is demonstrated to be unresponsive to appropriate treatment. Please refer to the benefits plan for more details.
What coverage and requirements are specified by Medicare?
Medicare offers bariatric surgery to beneficiaries with a BMI of 35 or greater and at least one severe weight-related problem (such as diabetes, heart disease or sleep apnea); all other medical treatments for obesity and related conditions must be ruled out. Documented evidence in your medical records of repeated failure to lose weight in medically supervised weight loss programs (diet, exercise programs/counseling or drug therapy) is required. Medicare requires surgery to be performed at a Medicare-approved "Center of Excellence" (including UW Health Surgical Weight Management Program) and that the specific procedure used is approved by Medicare.
Your out-of-pocket costs will depend on which type of plan you receive your Medicare coverage from:
- Original Medicare Plan: Medicare covers 80 percent of the approved amount. You are responsible for the remaining amount.
- MediGap/Medicare Supplemental Plan: Call and ask what is covered by the plan. Many times with MediGap plans, you will pay little or nothing.
- Medicare Advantage Plan: Call and ask what is covered. The plan must cover at least what Original Medicare does, but it may cover more.
When will I be able to have surgery?
How quickly you start the program will depend on the requirements for surgery as specified by your plan. Following successful completion of your assessment and pre-surgery education requirement, our team will review your progress in class and make sure all tests and studies your surgeon has ordered have been done and the results reviewed. It is possible that additional visits, tests or follow-up with one or more members of our team may be required prior to proceeding with surgery. When we are certain that you are adequately prepared for bariatric surgery and committed to maintaining the necessary lifestyle, we will submit a prior authorization form to your insurer. The prior authorization form is a formal request for coverage and payment of your bariatric surgery. Please note that your insurer may take up to 30 days to respond to this request. Once your insurer approves coverage of your bariatric surgery, someone from our program will contact you to assist with scheduling your pre-surgery labs, clinic appointments and surgery date.