Weight loss surgery is not one single procedure but includes a number of different surgical procedures from gastric bypass to gastric banding (lap banding). In contrast to fat removal surgery, weight loss surgery attempts to block the body from absorbing fat and nutrients. The patient eats or absorbs fewer calories so new fat is not added to the body. Moreover, since the body is getting much fewer calories from the diet after the surgery, existing body fat gets metabolized into energy. As a result, the patient enjoys weight loss—a rather massive weight loss, actually.
Weight loss surgery falls into two categories: restrictive and malabsorptive. Restrictive weight loss surgery decreases the size of the stomach either by removing a large portion of the stomach or by placing a band around the stomach. The goal of restrictive obesity surgery is to make the patient feel full faster and get them to stop eating, basically.
In malabsorptive bariatric surgery the stomach and intestines are repositioned so that swallowed food bypasses the areas of the intestine that absorb the most calories. In the malabsorptive approach, calories and nutrients pass through the body instead of being absorbed and converted into fat.
Some types of weight loss surgery are a combination of restrictive and malabsorptive. For example, in gastric bypass, a large portion of the stomach is removed and the esophagus is reattached below the duodenum (where most nutrients are absorbed across the gut into the bloodstream).
People that have weight loss surgery generally have a massive weight loss and look great within 6 months to a year after the procedure. So why does health insurance often cover the cost of bariatric surgery when it hardly ever pays for a tummy tuck? The answer, as with most decisions made by health insurance companies, comes down to medical necessity. Overweight, obesity, and morbid obesity is a health crisis in the United States. These diseases lead to high blood pressure, Type II diabetes mellitus, cholesterol abnormalities, heart disease and stroke (among others). These are expensive diseases; medical insurance companies realize that it is cheaper to pay for a single weight loss surgery than it is to pay for decades of medications and hospitalizations for these obesity-related illnesses.
Getting an insurance company to cover the cost of obesity surgery is no walk in the park—it requires a significant amount of time, effort, paperwork and a committed team of medical professionals. Considering the cost of bariatric surgery can be around $30,000 it makes sense for patients to try to get reimbursement.
How do you get your insurance company to pay for weight loss surgery?
1. Make sure your health insurance company covers weight loss surgery. If not, you may need to switch companies.
2. Make sure your health insurance plan covers weight loss surgery, specifically. If not, talk to human resources at your place of employment or otherwise change your plan to one that covers bariatric surgery. Also, find out the specific criteria needed to qualify for coverage according to your plan.
3. Make sure you are sufficiently overweight. Well, actually you must be obese. How is that determined? By the Body Mass Index or BMI. Most insurers (and surgeons that perform bariatric surgery) require a minimum BMI in order to be considered. For surgeons it is a BMI of 35 but for insurers it is usually 40 (although this varies).
4. Have an obesity-related disease. There are a number that qualify but type II diabetes or heart disease qualifies. Most people with a BMI of 40 will have at least one qualifying disease; it just needs to be diagnosed by a physician.
5. Make a good faith effort to lose the weight through diet and exercise. Most companies want to see the client try to lose weight for a solid year before they will consider reimbursement. Document your weight loss plan with your physician, dietician and personal trainer. Create a paper trail of what you did to lose weight without surgery.
6. Ask your bariatric surgeon and primary physician to draft letters explaining the medical need for weight loss surgery.
7. Get preapproval from your company. You will need a physical letter in hand before the surgery or you may be left with the bill.
As always, make sure to follow the requirements of your plan to the letter and document every step. Many bariatric surgeons can help you in this regard, you just need to ask and be diligent.