QualChoice FEHB Weight Loss Surgery - How to Avoid a Denial

Your QualChoice – Federal Employees Health Benefits weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.

To request a free insurance check, click here to contact a top local surgeon. Alternatively, use the tool below to find out if you have coverage.

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QualChoice - Federal Employees Health Benefits 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 QualChoice – Federal Employees Health Benefits for bariatric surgery in the United States, you must meet the following criteria:

  1. Be between age 18 and 64
  2. Diagnosis of Morbid obesity, defined as
  3. Or

    • BMI 35 – 39.9 AND one of the following
      • Coronary heart disease
      • Diabetes mellitus
      • Clinically significant obstructive sleep apnea
      • Medically refractory hypertension

    Use this BMI Calculator to check your body mass index…

  4. Have a documented length of condition of at least 3 years
  5. The member has been evaluated by a psychiatrist
  6. Member must meet one of following:
    • Member has participated in clinically supervised nutrition and exercise program (including dietician consultation, low calorie diet, exercise counseling, and behavioral modification, and pharmacologic therapy, if appropriate), documented in the medical record. This clinically-supervised nutrition and exercise program must meet all of the following criteria:
      • Nutrition and exercise program must be supervised and monitored in a clinical setting and working in cooperation with dieticians and/or nutritionists
      • Nutrition and exercise program(s) must be for a cumulative total of 12 months or longer in duration and occur within 2 years prior to surgery
    • Proximate to the time of surgery, member must participate in organized multidisciplinary surgical preparatory regimen of at least three months duration in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member’s ability to comply with post-operative medical care and dietary restrictions.

Revision Requirements

Repeat bariatric surgery is considered medically necessary when the initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria), and when either of the following medical necessity criteria are met:

  • Conversion to a RYGB may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure
  • Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure

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.

QualChoice - Federal Employees Health Benefits 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.

QualChoice – Federal Employees Health Benefits does cover weight loss surgery, but your specific policy must include it in order for you get it covered.

Following are a list of QualChoice – Federal Employees Health Benefits 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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QualChoice - Federal Employees Health Benefits Weight Loss Surgery

Please see below for the procedures QualChoice – Federal Employees Health Benefits 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 QualChoice – Federal Employees Health Benefits:

Procedures That Are NOT Covered

The following procedures are NOT covered by QualChoice – Federal Employees Health Benefits:

QualChoice - Federal Employees Health Benefits Weight Loss Surgery

If QualChoice – Federal Employees Health Benefits 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 QualChoice – Federal Employees Health Benefits 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: