EmblemHealth Weight Loss Surgery - How to Avoid a Denial

Your EmblemHealth weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.

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Read and click below for additional weight loss surgery insurance details.

EmblemHealth Weight Loss Surgery

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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 EmblemHealth for bariatric surgery in the United States, you must meet the following criteria:

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

    • BMI 35 – 39.9 AND one of the following
      • Coronary heart disease and other atherosclerotic diseases
      • Medically refractory hypertension
      • Osteoarthritis.
      • Moderate to severe obstructive sleep apnea
      • Type 2 diabetes

    Use this BMI Calculator to check your body mass index…

  4. Absence of a specific obesity cause, such as
    • Endocrine disorders
    • Adrenal or thyroid conditions
    • Treatment of metabolic cause provided
  5. Absence of life-threatening condition that would not improve with surgery.
  6. Active participation within the last 2 years in a physician-directed weight-management program for 6 or more months without significant gaps (or 3 months if provided through a multidisciplinary bariatric surgery program). The program must include monthly documentation of all of the following components:
    • Vital signs including weight
    • Current dietary program
    • Physical activity (i.e., exercise program)
    • Behavioral interventions to reinforce healthy eating and exercise habits
    • Consideration of pharmacotherapy with U.S. Food and Drug Administration (FDA) – approved weight-loss drugs
  7. Psychological clearance by a mental health professional

Revision Requirements

Members are eligible for coverage of a surgical revision of a previous gastric restrictive surgery if it is medically necessary as a result of a complication of the original procedure, such as:

  • Staple disruption
  • Obstruction or chronic stricture
  • Severe esophagitis
  • Dilatation of the gastric pouch in a member who experienced appropriate weight loss prior to the dilatation

Surgical revision is not considered medically necessary for members who have a functional operation (without any evidence of medical abnormality) because of inadequate weight loss.

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.

EmblemHealth 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.

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

Following are a list of EmblemHealth 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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EmblemHealth Weight Loss Surgery

Please see below for the procedures EmblemHealth 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 EmblemHealth:

EmblemHealth Weight Loss Surgery

If EmblemHealth 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 EmblemHealth 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: