Even if your body mass index (BMI) classifies you as morbidly obese that doesn't mean your health insurance company will approve bariatric surgery. It’s more complicated than that.

There's no doubt that Americans are getting heavier. According to the Centers for Disease Control and Prevention, adult obesity rates doubled in the past 30 years. Nearly 40% of adults are considered obese. At least 20% of adults in every state are obese.

Best Health Insurance Offers For You
Valid zip code required
Get Quotes

Many have turned to bariatric surgery coupled with a change in diet and exercise as a way to lose weight. The American Society for Metabolic & Bariatric Surgery (ASMBS) estimated that the mortality rate for bariatric surgery after 30 days is about 0.13% -- or one in 1,000 people. The ASMBS also states that this mortality rate is lower than other operations, such as gallbladder and hip replacement surgeries.

Bariatric surgery’s benefits far outweigh the risks. Surgery can increase life expectancy by up to 89%. And after surgery, patients fare far better than they would have without it.

Obesity-related issues that are often improved as a direct result of the surgery:

  • High blood pressure
  • Sleep apnea
  • Asthma
  • Breathing disorders
  • Arthritis
  • Cholesterol abnormalities
  • Gastroesophageal reflux disease
  • Fatty liver disease
  • Venous stasis
  • Urinary stress incontinence

When could bariatric surgery be right for you?

Some overweight people turn to bariatric surgery when diets and exercise alone don’t work.

Bariatric surgery encompasses operations on the stomach, such as:

  • Gastric bypass (open and laparoscopic)
  • Laparoscopic adjustable gastric banding
  • Biliopancreatic diversion

These procedures dramatically restrict one's ability to eat, thereby causing weight loss. Those who undergo these procedures wind up with a smaller stomach that's able to hold only a few ounces. Eating too much can make that person feel ill.

In addition, some weight-loss surgeries alter the digestion process, limiting the absorption of calories and nutrients.

Doctors typically recommend surgery when a patient has a BMI of 40 or higher or 35 and higher if it's coupled with other obesity-related diseases, such as heart disease diabetes or sleep apnea. A BMI of 25 to 30 is considered overweight and 30 to 35 is considered obese. A person who is morbidly obese typically has a BMI above 35.

Dr. Richard A. Perugini, surgeon and director of the Bariatric Surgery Department of UMass Medical Center in Worcester, MA, said it's not always the numbers that make a person decide to have the operation.

"The onset of medical conditions, especially type 2 diabetes mellitus, are common triggers. Bariatric surgery is probably the most powerful tool to treat diabetes. It leads to improved quality and duration of life. For others, the goal is to live a more active life, perhaps to play with children or grandchildren," he said.

Perugini stressed, however, that not all people who want the surgery get approved. His hospital screens individuals to see if they’re eligible. That includes checking with the individual insurer’s criteria for surgery and behavioral health evaluations.

"We try to be attuned to social support structures. Some medical conditions, such as cirrhosis, serious cardiac or pulmonary disease, require a thorough evaluation and treatment prior to performing bariatric surgery,” he said.

Will health insurance pay for bariatric surgery?

The average bariatric surgery costs $17,000 to $26,000, according to the ASMBS. Mounting evidence shows that surgery for morbid obesity can be more cost-effective than treating the conditions resulting from obesity. However, even with your doctor's recommendation, your health insurance might not pay for the surgery.

ASMBS said the most common reasons that patients don't undergo laparoscopic gastric bypass surgery are insurance denial and not getting pre-authorization before the procedure. Insurers deny about 25% of patients considering bariatric surgery three times before giving approval. If you're considering bariatric surgery and want your health insurance to pay for it, you may have to jump through a few hoops.

Perugini, though, said don't let insurance scare you away from the procedure.

"In the vast majority of cases, insurance covers bariatric surgery. Contact your insurance carrier to determine if elective bariatric surgery is a covered benefit through your plan," he said. "And if your case is denied by insurance, there is an appeals process."

Know your policy’s terms before scheduling bariatric surgery. Is obesity surgery specifically excluded in your policy? Do you need pre-authorization?

Your insurer will likely require a full medical work-up along with the pre-authorization request. They’ll also probably want documented physician-supervised weight-loss attempts. Insurers rarely cover weight-loss programs themselves; programs like Weight Watchers and Jenny Craig don't count.

You'll find out exactly from your insurer what documents you request a pre-authorization. Insurers demand pre-authorizations for many procedures and tests as a way to reduce what it deems unnecessary. Regardless, expect it to involve volumes of paperwork. Your doctor will help you and may even work with the insurer to get approval.

Coverage for weight-loss surgery varies widely, as do insurers' definitions of "medically necessary." Here's information from two major insurers -- Aetna and CIGNA.

Aetna

Aetna doesn’t offer any individual health plan that covers bariatric surgery. Most Aetna group HMO and POS plans exclude coverage of surgical operations, procedures or treatment of obesity unless approved by Aetna.

For Aetna plans that cover bariatric surgery, here is a summary of the criteria for gastric bypass approval:

The patient must be morbidly obese for at least two years, with a BMI of 40 or more or have BMI greater than 35 in conjunction with any of the following: coronary heart disease, Type 2 diabetes mellitus, clinically significant obstructive sleep apnea or medically refractory hypertension.

In addition to that, you'll have to:

  • Have attempted weight loss in the past without successful long-term weight reduction
  • Have participated in a "physician-supervised nutrition and exercise program" or a "multi-disciplinary surgical preparatory regimen," each with their own criteria.

The full list is available on the Aetna site under Clinical Policy Bulletin: Obesity Surgery.

CIGNA

CIGNA said bariatric surgery coverage is an option available under Cigna's group medical plans, and clients can choose to include it. Right now, most CIGNA customers in employer-sponsored plans have that coverage.

Nearly all plans cover obesity screening, behavioral counseling and nutritional screening and counseling as a standard.

When eligible for coverage under the benefit, you must meet medical necessity. Some plans elect to have a dollar maximum, while some do not. State mandates and the Affordable Care Act rules impact the ability to apply a dollar maximum.

When CIGNA coverage is available, a patient is required to have:

  • Reached age 18 or full skeletal growth.
  • A BMI of more than 40 for at least the past 24 months or a BMI of 35-39.9 for at least the past 24 months plus at least one clinically significant obesity-related comorbidity, such as type 2 diabetes or pulmonary hypertension.
  • Active participation within the last two years in a physician-directed weight-management program.
  • An evaluation within the past 12 months, including an assessment by a surgeon qualified to perform bariatric surgery recommending surgical treatment, a separate medical evaluation recommending bariatric surgery, clearance for surgery by a mental health provider and a nutritional evaluation by a physician or registered dietician.

CIGNA also covers medically necessary reversal for bariatric surgery when a patient has complications. Under certain circumstances, it also covers the revision of a previous bariatric procedure when the patient has not lost adequate weight.

To be fully prepared for the process, CIGNA said patients should schedule regular check-ups; be aware of BMI; monitor blood pressure; exercise; and take full advantage of preventive services, such as obesity screening, counseling and diabetes prevention programs that are available at no extra cost.

When bariatric surgery is required and medically necessary, customers should consult coverage documents, call their carrier or work through their doctor to verify coverage and any limitations before pursuing surgery.

Currently, all evidence-based, medically necessary bariatric approaches are covered, as defined in CIGNA's published Coverage Policy. CIGNA said there are a wide array of procedures available. This ensures that customers with coverage have access to the most appropriate bariatric surgery approach specific to their condition and needs.

What to do if you get declined for bariatric surgery

Even if your policy covers bariatric surgery coverage, brace yourself for a possibly long claims process. At best, you'll need mounds of documentation to show the surgery is medically necessary for you.

Or you may run into big roadblocks. For CIGNA, the main reason for denials is that the insurer doesn’t believe the member met the necessary criteria. In other instances, an employer may not include bariatric surgery in its plan.

If your plan doesn't exclude coverage and you're denied, appeal it. You will probably need to provide further documentation of your need for the surgery as medically necessary.

All health insurance plans should have a clear appeals process. Find out what it is and follow directions. You may only have a limited time from the date you were denied or had the procedure to get an appeal underway, possibly only 60 days. Depending on your plan's procedure, you might have to start with a phone complaint and then move to a written appeal.

CIGNA said if a customer has coverage, but medical necessity was not met and a denial was issued, a medical necessity appeal is available to the member or provider. The denial letter would provide the contact information and instructions to initiate the appeal.

If you’re thinking about appealing:

  • A good place to start is your company’s human resources department if your insurance is through your employer. HR can check to see whether the policy actually covers the surgery and could contact the insurance company.
  • If you go through with the appeal, talk to your physician and collect any information that will help your case. For instance, ask your doctor for a letter about why the surgery is needed. Some bariatric surgeons even have "appeals experts" on staff that have experience in getting claims paid after denial. Collect any medical records that may help. Think about your family’s medical history.
  • Craft a letter focused on the decision and why the insurer should reconsider. Keep it to the facts. Don’t get into any emotional reasons why the insurer should approve.
  • Keep meticulous records of your contact with the insurer and your appeal.
  • If it’s denied again, see if there’s a second appeal process or an external appeal.
  • If you still get denied, contact your state Department of Insurance. The departments have staff people who help consumers with denials.

If you've tried everything and you're still getting denied, there are a few other options:

  1. If your HMO plan doesn't cover obesity surgery, change to a PPO plan at open enrollment if the PPO plan covers it.
  2. Change to your spouse's plan if it provides coverage.
  3. Get a new job. Certain large employers cover weight-loss surgery as a commitment to employee health.
  4. Consider paying out-of-pocket and ask your surgeon's office about payment plans. According to the ASMBS, there are also loans available.

Perugini had some advice for those on the fence.

"Bariatric surgery is a powerful tool. The biggest piece of advice I can give is that long-term success is due to healthy habits. We all have to employ healthy habits. This goes for patients and for practitioners that work in the weight center. We need to plan well to eat frequent meals. We need to eat good quality food. We need to be active.

“However, I feel the most important thing about making healthy habits a lasting part of our lives is that they should feel good. We, as humans, do not do well with deprivation. We should be able to savor our meals. Exercise should be an experience that makes us feel good and that we look forward to. And if and when life gives us particularly stressful challenges, it helps to have a support system to rely on," he said.