CHAMPVA Weight Loss Surgery - How to Avoid a Denial

Your Civilian Health and Medical Program of the Department of Veterans Affairs weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.

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champva Weight Loss Surgery

READ THIS FIRST

Even if your insurance company covers bariatric surgery in some plans, that does not mean that your specific plan covers it. The obesity surgery approval requirements in this section assume that weight loss surgery is covered by your specific policy.

To confirm whether your specific policiy covers bariatric surgery, click here to contact a surgeon and ask for a free insurance check.

Disclaimer: The information contained on this page may not include all components of your insurance company’s medical policy and/or may not be up to date. Contact your insurance company to confirm all benefits.

In order to be approved by CHAMPVA for bariatric surgery in the United States, you must meet the following criteria:

  1. Be of age 18 years or older
  2. Diagnosis of Morbid obesity, defined as
  3. Or

    • BMI 35 – 39.9 AND one of the following
      • Cardiovascular disease
      • Type 2 diabetes mellitus
      • Obstructive sleep apnea
      • Pickwickian syndrome
      • Hypertension
      • Coronary artery disease
      • Obesity-related cardiomyopathy
      • Pulmonary hypertension

    Use this BMI Calculator to check your body mass index…

  4. The patient has been previously unsuccessful with medical treatment for obesity. Failed attempts at non-surgical medical treatment for obesity must be documented in the patient’s medical record
    • Commercially available diet programs or plans, such as Weight Watchers®, Jenny Craig, or similar plans are acceptable methods of dietary management, if there is concurrent documentation of at least monthly clinical encounters with the physician
      • NOTE: These programs are not covered by CHAMPVA
    • Physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement

Revision Requirements

Medically necessary surgical reversal, that is, takedown or revision of the bariatric procedure is covered when the beneficiary develops a complication, such as stricture or obstruction from the original covered surgery

Replacement of an adjustable band because of complications, such as port leakage, slippage that cannot be corrected with band manipulation or adjustments is covered

Repeat/revision of a covered bariatric surgical procedure due to technical failure of the original procedure is covered when all of the following criteria are met:

  • The patient has failed to achieve adequate weight loss, which is defined as failure to lose at least 50% of excess body weight or failure to achieve body weight to within 10% of ideal body weight at least two years following the original surgery
  • The patient met all the screening criteria, including BMI requirements of the original procedure, and has been compliant with a prescribed nutrition and exercise program following the original surgery
  • The requested procedure is a covered bariatric surgery
  • NOTE: Inadequate weight loss due to individual noncompliance with postoperative nutrition and exercise recommendations is not a medically necessary indication for revision or conversion surgery and is not covered

If Your Policy Does NOT Cover It: Seek Partial Coverage

You may be able to get part of the costs paid for by insurance even if weight loss surgery isn’t covered. It’s all about how your doctor and hospital submit your claims to your insurance company.

For example, there are many non-bariatric surgery reasons for your doctor to recommend:

  • Cardiology exam
  • Lab work
  • Medically supervised diet program
  • Psychological exam
  • Sleep study

These are ordered for many reasons other than bariatric surgery and may be covered as a result. If your doctor submits one of these claims using a weight loss surgery CPT code (Current Procedural Terminology Code), your insurance is unlikely to cover it. But if your doctor uses a general CPT code, it probably will be covered.

While this may sound “sneaky”, it is an ethical practice. After all, these tests will be beneficial regardless of whether you move forward with surgery.

champva Weight Loss Surgery

Before getting into the types of insurance plans, you can cut to the chase by contacting a local bariatric surgeon’s office. Most surgeons will contact your insurance company for free to confirm whether or not you’re covered.

Click here to find a local surgeon and ask them to check your insurance for you for free.

CHAMPVA does cover weight loss surgery, but your specific policy must include it in order for you get it covered.

Following are a list of CHAMPVA plan types and whether they cover bariatric surgery:

Weight Loss Surgery for Health Plans Through Your Work

If you work for a company that has 50 or more full time employees, it is completely up to your employer to decide whether or not to cover bariatric surgery under your health plan.

To find out whether weight loss surgery is covered by your employer’s plan, you have a few options:

Weight Loss Surgery for Individual/Family Plans

The Affordable Care Act (Obamacare) requires all individual and small group plans (less than 50 full time employees) to include weight loss surgery coverage as long as it is considered an “Essential Health Benefit” in your state.

The following states DO currently consider bariatric surgery an Essential Health Benefit (bariatric surgery is covered by all individual, family and small group plans in these states):

Your State Not on the List?

If your state is NOT on the list, then weight loss surgery is probably NOT covered under your plan.

First, contact your local surgeon to be sure. For no charge, their office will contact your insurance company on your behalf to work through the details.

If your surgeon confirms that your policy does not include obesity surgery, you still have several options for making surgery more affordable. See these pages for more information:

    • Arizona
    • California
    • Delaware
    • Hawaii
    • Illinois
    • Iowa
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Oklahoma
    • Rhode Island
    • South Dakota
    • Vermont
    • West Virginia
    • Wyoming

Regardless of whether your state is on the list, contact a qualified surgeon to request a free insurance check to verify your coverage.

To review your insurance company’s obesity surgery coverage requirements, click here to jump back up the page.

Weight Loss Surgery for Medicare Plans

All Medicare plans are required to cover the following weight loss surgery procedures:

However, special Medicare-specific criteria apply. Click here to learn more about Medicare bariatric surgery coverage.

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champva Weight Loss Surgery

Please see below for the procedures The Civilian Health and Medical Program of the Department of Veterans Affairs covers, might cover under certain circumstances, and those that are not covered under any circumstances:

Procedures That ARE Covered

Procedures That MIGHT BE Covered

The following procedures MIGHT BE covered by CHAMPVA:

champva Weight Loss Surgery

If CHAMPVA denies your weight loss surgery claim and you think it should be covered, consider filing an appeal.

Our Health Insurance Appeals page will get you started, then head over to the Disputes & Appeals page for CHAMPVA to learn how to proceed.

Search the weight loss surgeon directory below to ask a top surgeon about a free insurance check by country and region: