How to get insurance to pay for weight loss surgery

by Janice Crane
(Alexandria, NH)

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How do I qualify for weight loss surgery so that insurance will pay for it?

I am a 57 years old with a history of chronic back pain, depression and high blood pressure. I have a family history of diabetes, strokes and osteoarthritis with joint replacements.

My weight is 215 pounds and has been this way for the past 10 years. Physically I do walk, but after doing it I hurt, standing in one place for very long I hurt, and also after sitting I hurt. I do swim for exercise when I can get there which is 30 minutes away.

I eat a good diet and I am not a big eater. My downfall on eating is bread and sweets. So with no children in the house I do not bake. My husband and I eat the same foods and in a year’s time his cholesterol went down 25 points with no drugs except for dietary supplements.

I do believe if the weight is off I could maintain it and I would feel better. What do you think?

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No bariatric surgery coverage in the Healthcare Marketplace

by: Jeff

Hi Beck,  

Unfortunately, if your state's plans do not include coverage, you will be unable to have it added to the plan. You can check to see if your state has coverage on our weight loss surgery insurance page. 

Getting it added would be up to the state, so I suppose you could contact your congressman and share this link with them (or print out a copy of that section for them to review if you visit them in person).  

In the mean time, there are several financing options to make surgery more affordable as well as creative ideas to reduce your out of pocket costs (click links to learn more).  

Good luck, and please keep us posted!  
Jeff

No coverage in HC Marketplace

by: Beck

Jeff:

You provided info on getting your insurance to add Bariatric Surgery (if your employer has 51+ employees) but what if you're on the state HC marketplace (Obamacare)? Florida doesn't consider it an Essential Health Benefit.

I'm ready to give up. I've gained and lost the same 5 pounds for about 10 years now. I can't get rid of it permanently and I can't get past it.

Now what?

What can I do?

by: Kali

Hi,

I am 24 with two kids and after my daughter I developed hypothyroidism and I have major back problems as well as high blood pressure. I am 5"5 and weight 245 lbs. I have issues walking and standing for long period of time because of my weight and bad back. My BMI is 40.8.

I am part Cherokee and have Medicaid. Does anyone know of I am able to get the Indians and Medicaid to at least help pay for some?

Thank you. I've tried dieting and walking (can't do to much exercising because of back).

A letter to my company about bariatric surgery

by: Rick

I was hoping to find reasons that I could present my company with that would convince them to add bariatric surgery to our policy. I need to write a letter and I could use all the help I can get. They always fire back with "It will increase the premiums".

My wife has needed this surgery for several years and every time I follow a lead I hit a wall. She has been a stay at home Mom for 30 years and has 4 work credits so she can't get disability or medicare (55 yrs old).

I offered to sell my house but the doctor said because of my wife's complications he would require the deep pockets of an insurance company. She has had all of the prerequisites (classes, diets, therapy) but I still can't get her the help she needs!

BCBS denied me for Bariatric Surgery

by: Carlton McCall Jr

I was 200% denied for Bariatric Surgery.

I was told by BCBS they won't pay even if it's to save my life. I live in NC and I'm 5'11" tall, 416 Pounds, and I'm 46yrs old.

I'm trying to loss weight. Not sure how much weight I need to loss to avoid a sleep study. I'm considering paying for the surgery out of pocket.

need a weight loss surgery

by: carol daniel

I have tried every thing to loose weight, at 380. I try to eat a good died, it's just me and my husband. I do eat a sweet now and then, I suffer from depression and anxiety. I am broader line diabetic, my family has blood sugar and cholesterol problems.

I know it's only a matter of time for me. I am not a big eater but I need help.

insurance denial

by: kim

I too was denied by BCBS federal of New York. I'm 5"2 weight in at 230 lbs BMI. I believe this is a BMI of 42 and they denied me because my BMI in 2011 was 35.

So because back in 2011, with a BMI at 35, it was denied. Now I have problems with my knees and they said to try back in June to apply again. Its so sad what these insurance companies put you threw. You pay you're premium every month and they don't want to help you.

Get Your Policy

by: Lap Band Groupie

Jeff covered it all, but I just wanted to say that you can get your insurance policy info from your company (usually HR) or from the insurance co. directly (many times they can tell you how to print it online).

Ask for the 'Bariatric Policy/Rider". Read it carefully and follow it to the letter. Make sure your BMI is over 35 before you go for your first visit to the Doc (and hypertension is one of the comorbidities that counts if you're on medication for it…the rest of the things you mentioned don't count…diabetes only counts, again, if you have an official diagnosis on record).

Best wishes!
Lap Band Groupie

Getting insurance to pay for weight loss surgery

by: Jeff

Hi Janice,

Assuming that you've calculated your body mass index (BMI) to be at least 40 or at least 35 alongside at least one clinically significant comorbidity, getting insurance (in the United States) to pay for weight loss surgery really depends on your employer.

Individual plans do not usually cover it, unless you have Medicare, in which case weight loss surgery is covered for individuals.

Assuming you have insurance through your (or your partner's) employer, the easiest way to find out if it's covered is to review your plan documents, speak with your Human Resources department or contact your insurance company. If you find out that it's covered, click here to learn the next steps for getting insurance to pay for weight loss surgery. If you find out that weight loss surgery is not covered by your employer-sponsored plan and want to try to convince your company to add it, there are several very plausible business reasons for them to do so.

Share these business reasons to add weight loss surgery to your company's insurance plan with your HR folks.

Keep in mind that if your insurance doesn't cover weight loss surgery (or for whatever portion it doesn't cover like coinsurance or deductibles), there are several financing options to make it more affordable, including:

1. Payment Plan Through a Qualified Bariatric Surgeon - This is probably your most realistic and affordable local non-insurance option - contact a local qualified weight loss surgeon to learn your options.
2. Friends & Family
3. Secured Medical Loans
4. Retirement Plan Loans
5. Permanent Life Insurance Loans
6. Brokers, Direct Lenders and Credit Cards (Unsecured Medical Loans)
7. Medical travel: a worthy consideration

Click here to learn more about each of these bariatric surgery financing options.

I hope that helps!

Jeff

Overweight and depressed

by: Jacqueline scott

I'm a 55 yr old woman. I've been trying all kinds of diets. I have high cholesterol and bp, diabetes, rheumatoid arthritis, and a body mass index of 56. I need help.

My insurance company excludes weight, I don't know what else to do please help. I'm a mother of 2 and grandmother of 5 loving grandchildren.

I need help I've fallen into depression stage. I don't leave the house much my back and knees limit me.

Here's my email, please contact me:
jacquelinescott5214@yahoo.com

Gastric Bypass

by: CarolH

My friend had bariatric surgery a year ago and is doing great. But she fought or 3 years to get the help she needed to pay for the surgery. She was on Medicaid.

Every 4th or 5th person I see is obese. I read somewhere that the average cost of bariatric surgery is $23,000 and the cost of the band is $14,000. No wonder more people can't afford the surgery.

States need legislation to make all insurance companies pay for gastric bypass/bands. Doctors need to stop thinking about how much money they can make and not charge so much. Obesity can kill you, its a life threatening disease. I can't do anything as one person but together we can fight the insurance companies and doctors.

I Feel Your Pain

by: Nisey - St. Louis, MO

Hi:

I was reading all of your comments. I stumbled onto this site while I was researching insurance for gastric sleeve and I didn't realize how many people are feeling the same way that I do and I also don't understand why insurance companies won't honor this surgery. It would be beneficial to both the insurer and the insured.

I think that we should all ban together and begin writing the government asking for a change in insurance policies to begin acknowledging that it would cost insurance companies far less to allow people who are obese to get some type of gastric surgery to better the health situations (less health problems, less medication).

There has to be some way to get insurance companies to understand the need for this.

BCBS

by: Kathy

Hi,

I have BCBS of Oklahoma, which is an essential benefits state and they still would not cover my weight loss surgery with no explanation (at least none from my doctor's office).

I am at my wit's end.

Second surgery?

by: Natalie

I had gastric bypass in 2003, and lost from 300 lbs down to 200 lbs. Since then I have been forced to lead a sedentary life because of SLE lupus, fibromyalgia, and osteoarthritis.

I have had both knees replaced, 6 spinal surgeries, including 3 fusions, 5 ankle surgeries, including ankle replacement, and rotator cuff surgery.

I'm a mess!

Depressed, housebound (haven't been able to drive in 2 years, had to retire from work), and unable to exercise. I'd love to get the sleeve and hopefully be able to lead an active life again. I'm 54 and not ready to give up yet.

Since I already had gastric bypass (mostly covered by BCBS), would a surgeon even consider me for the sleeve? Anyone have any experience with my situation?

My insurance company EXCLUDES weight loss

by: Shawne K.

I'm having trouble finding information, I'm hoping someone can help. My employer recently changed insurance companies. Our former insurance covered weight loss, but at the time I didn't need it. Since then, we have a new insurance company that excludes all weight loss options, and I have packed on the pounds out of nowhere and now need it. Diet and exercise aren’t cutting it.

Everything I look up on the internet says appeal, appeal, appeal, but that only applies to insurance companies that offer weight loss surgery but have denied someone. They are not taking into consideration or telling you what to do when your insurance companies SPECIFICALLY EXCLUDE any weight loss options. I can't find any information out there on what to do if bariatric surgery is not covered AT ALL. There has got to be recourse for people who can’t cough up the cash, like me.

I called and asked my insurance company if there was an appeal process and if so, what kind of success rate did an appeal have. The rep said yes, I can appeal, but the answer will be no, they've never, ever covered weight loss surgery even with an appeal. Reading between the lines, I took it to mean I could appeal all I want, as often as I wanted, but I would be wasting my and my doctors' time. I have at least 6 doctors that would sign something stating getting this surgery is a matter of life and death for me. Wouldn't matter. They don't care.
I'm frustrated because they would rather treat my obesity diseases and see me suffer, than to give me an opportunity to be healthy. I'm not doing this for vanity to strut around the beach in a bikini. I'm trying to save my life from a combative, unresponsive to diet and exercise body.
Here are my questions:

How can I force my insurance company to cover this to save my life?
If they all out refuse, can I hire a lawyer and sue my insurance company for not paying for this surgery if I develop diabetes or some other fat disease that could have been prevented if they'd have helped me? I'm borderline right now, have stasis dermatitis, and was recently diagnosed with uterine cancer, of which one of the causes is obesity. I would LOVE to be able to sue them for that, for not helping me and throwing me to the dogs. Has anyone tried suing? Also, if legislation in your state says they have to provide it, and they aren't, how are they getting around it without getting sued? I work for a company of about 4k employees (Maine).

Does anyone have any tips or idea on how to get this expensive, lifesaving procedure paid for since I can’t afford it? I don’t think a Go Fund Me will work, my friends and family are poor, too. Are there any charities out there who will help?

Thank you.

what next ?

by: Guy Grande

Just contacted BCBS they say that weight loss surgeries simply for a diagnosis of Morbid Obesity code E6601 are excluded, but that I might get approved if it were for other conditions. This is a list of my conditions:

50 y/o Male
BMI 63 5'11" 325lbs
Obstructive Sleep Apnea
High Blood Pressure
Hypothyroidism
Depression
Edema

How is the best way to to pursue approval based on other conditions beside morbid obesity ?

Insurance doesn't cover bariatric sugery

by: Ellen S

Employer just recently changed insurance companies. This new insurance company does not cover bariatric surgery. I am in desperate need of the surgery and I don't know where to turn. Paying out of pocket is huge. What can you do to figure out how to get the surgery without paying over $20,000.00?

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