Even if your body mass table of contents (BMI) classifies you together morbidly obese the doesn’t median your health and wellness insurance firm will approve bariatric surgery. It’s more facility than that.

You are watching: Does masshealth cover weight loss surgery

There’s no doubt that Americans are obtaining heavier. Follow to the Centers for an illness Control and Prevention, adult obesity rates doubled in the past 30 years. Virtually 40% of adult are thought about obese. At least 20% of adults in every state space obese.

Many have turned to bariatric surgery coupled with a change in diet and exercise as a method to shed weight. The American society for Metabolic & Bariatric surgical procedure (ASMBS) approximated that the mortality price for bariatric surgery after 30 days is around 0.13% — or one in 1,000 people. The ASMBS additionally states the this mortality rate is lower than various other operations, such as gallbladder and also hip replacement surgeries.

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

Obesity-related problems that are regularly improved together a direct an outcome of the surgery:

High blood pressureSleep apneaAsthmaBreathing disordersArthritisCholesterol abnormalitiesGastroesophageal reflux diseaseFatty liver diseaseVenous stasisUrinary anxiety incontinence

Bariatric surgery incorporates operations on the stomach, such as:

Gastric bypass (open and also laparoscopic)Laparoscopic adjustable gastric bandingBiliopancreatic diversion

These procedures dramatically restrict one’s capability to eat, thereby leading to weight loss. Those that undergo these steps wind up v a smaller sized stomach that’s maybe to host only a few ounces. Eating too much deserve to make that human feel ill.

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

You’ll likely likewise take part in nutritional and behavior great to aid you v the surgery and also life after the surgery.

Key Takeaways

Bariatric surgery are steps that change the digestive system to assist patients shed weight.The median bariatric surgery expenses $17,000 to $26,000, but betterworld2016.orgrs generally pick up many of those prices if the patient meets requirements.Beyond obesity, bariatric surgery have the right to also assist patients with high blood pressure, sleep apnea, breath disorders and other life-threatening problems.There’s always risk with any surgery, but bariatric procedure benefits far outweigh the risks, professionals say.

Weight-loss surgical procedure requirements

Bariatric and gastric bypass surgical treatment isn’t because that everyone. You require to meet criteria come be considered a candidate.

Mayo Clinic said world who are commonly eligible for weight-loss surgery:

Have been unsuccessful in losing weight after enhancing diet and exerciseHave a BMI that 40 or higherHave A BMI of between 35 and 40 and also weight-related health and wellness problems, such as kind 2 diabetes and high blood pressure

If your BMI is under 35, you might still it is in eligible if your weight is top to significant weight-related wellness problems.

Dr. Richard A. Perugini, surgeon and also director of theBariatric surgery Department that UMass clinical Centerin Worcester, MA, claimed it’s not constantly the numbers the make a person decide to have the operation.

“”The start of clinical conditions, especially type 2 diabetes mellitus, are common triggers. Bariatric surgical treatment is probably the most an effective tool come treat diabetes. It leader to improved quality and duration the life. For others, the score is to live a more active life, maybe to beat with youngsters or grandchildren,”” that said.

Perugini stressed, however, that not all world who want the surgery get approved. His hospital screens individuals to view if they’re eligible. That consists of checking with the individual betterworld2016.orgr’s criteria for surgery and also behavioral health and wellness evaluations.

“”We shot to be attuned to social assistance structures. Some clinical conditions, such as cirrhosis, serious cardiac or pulmonary disease, call for a thoroughly evaluation and treatment before performing bariatric surgery,” the said.

How lot does weight-loss surgical procedure cost?

The median bariatric surgery expenses $17,000 come $26,000, according to the ASMBS. Mounting evidence shows that surgical procedure for morbid obesity have the right to be more cost-effective than treating the problems resulting native obesity. However, even with your doctor’s recommendation, your wellness insurance might not pay for the surgery.

The exact cost differs through surgery, circumstances and potential complications. However, ASMBS approximated that the surgical treatment usually leads to lower health care costs and improved worker productivity, i m sorry are factors why wellness plans usually provide the surgical treatment if girlfriend qualify.

Will health and wellness insurance pay for bariatric surgery?

Health betterworld2016.orgrs typically pay for bariatric surgical treatment if you meet requirements.

ASMBS said the most common reasons the patients don’t undergo laparoscopic gastric bypass surgery room insurance denial and not obtaining pre-authorization before the procedure. betterworld2016.orgrs deny about 25% of patients considering bariatric surgical treatment three times before giving approval. If you’re considering bariatric surgery and want your health insurance to pay for it, friend may need to jump through a few hoops.

Perugini, though, stated don’t let insurance scare you away from the procedure.

“”In the vast bulk of cases, insurance covers bariatric surgery. Call your insurance transport to recognize if elective bariatric surgery is a covered benefit through her plan,”” that said. “”And if your situation is denied by insurance, there is an appeals process.””

Know your policy’s terms before scheduling bariatric surgery. Is weight problems surgery particularly excluded in her policy? carry out you need pre-authorization?

Your betterworld2016.orgr will likely require a full medical work-up together with the pre-authorization request. They’ll also probably want recorded physician-supervised weight-loss attempts. betterworld2016.orgrs rarely cover weight-loss program themselves; programs choose Weight Watchers and Jenny Craig don’t count.

You’ll discover out precisely from your betterworld2016.orgr what records you request a pre-authorization. betterworld2016.orgrs need pre-authorizations for plenty of procedures and tests together a way to mitigate what that deems unnecessary. Regardless, mean it come involve volumes of paperwork. Your physician will assist you and also may also work with the betterworld2016.orgr to get approval.

Coverage because that weight-loss surgical procedure varies widely, as carry out betterworld2016.orgrs’ interpretations of “”medically necessary.”” Here’s info from two significant betterworld2016.orgrs — Aetna and also CIGNA.


Aetna doesn’t offer any kind of individual health arrangement that covers bariatric surgery. Most Aetna team HMO and also POS to plan exclude coverage of operation operations, steps or therapy of obesity unless authorized by Aetna.

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

The patient have to be morbidly obese for at the very least two years, with a BMI the 40 or much more or have actually BMI better than 35 in conjunction with any type of of the following: coronary heart disease, type 2 diabetes mellitus, clinically far-reaching obstructive sleep apnea or medically refractory hypertension.

In enhancement to that, you’ll have actually to:

Have attempted weight loss in the past without successful permanent weight reductionHave participated in a “”physician-supervised nutrition and also exercise program”” or a “”multi-disciplinary operation preparatory regimen,”” each with their own criteria.

The complete list is accessible on the Aetna site under Clinical policy Bulletin: weight problems Surgery.


CIGNA stated bariatric surgical treatment coverage is one option available under Cigna’s group medical plans, and also clients can choose to incorporate it. Best now, most CIGNA customers in employer-sponsored plans have actually that coverage.

Nearly all plans cover excessive weight screening, behavior counseling and also nutritional screening and also counseling together a standard.

When eligible for coverage under the benefit, you must satisfy medical necessity. Some plans selected to have a dollar maximum, when some do not. State mandates and also the Affordable treatment Act rules impact the ability to use a dollar maximum.

When CIGNA coverage is available, a patience is forced to have:

Reached period 18 or full skeletal growth.A BMI of an ext than 40 for at the very least the previous 24 months or a BMI the 35-39.9 because that at the very least the previous 24 months plus at the very least one clinically far-ranging obesity-related comorbidity, together as type 2 diabetes or pulmonary hypertension.Active participation in ~ the last two years in a physician-directed weight-management program.An evaluation within the previous 12 months, consisting of an evaluate by a operated doctor qualified to perform bariatric surgical procedure recommending operation treatment, a separate medical evaluation recommending bariatric surgery, clearance for surgical treatment by a mental health and wellness provider and also a nutritional evaluation by a physician or registered dietician.

CIGNA likewise covers medically necessary reversal because that bariatric surgery once a patient has actually complications. Under specific circumstances, it likewise covers the review of a previous bariatric procedure as soon as the patient has not lost adequate weight.

To be totally prepared for the process, CIGNA said patients must schedule consistent check-ups; be conscious of BMI; monitor blood pressure; exercise; and also take full benefit of preventative services, such as excessive weight screening, counseling and also diabetes prevention programs the are accessible at no extra cost.

When bariatric surgical procedure is required and medically necessary, customers have to consult coverage documents, speak to their carrier or occupational through their physician to verify coverage and also any limitations before pursuing surgery.

Currently, every evidence-based, medically essential bariatric ideologies are covered, as identified in CIGNA’s published Coverage Policy. CIGNA claimed there are a broad array of steps available. This ensures that customers v coverage have accessibility to the most suitable bariatric surgical procedure approach particular to their condition and needs.

Does Medicare covering bariatric surgery?

Medicare covers part weight-loss surgeries, including laparoscopic banding surgery and gastic bypass surgery.

You require to fulfill requirements and deemed severely obese. You and your doctor require to get pre-approval for weight-loss surgery.

Similar to other betterworld2016.orgrs, Medicare will most likely require a BMI of at the very least 35, your weight must also be resulting in serious health and wellness issues and also you’ve attempted for years to shed weight with diet and also exercise.

How lengthy does it take it Medicaid to grant weight-loss surgery?

Medicaid also permits weight-loss surgeries if you accomplish criteria, but recent studies present approval do take longer.

betterworld2016.orgrs generally take a month to grant weight-loss surgeries. However, wait times for Medicaid approval have the right to take five months or more.During that time, medical allowance will testimonial your records and also input from your doctor before making the decision.

What to carry out if girlfriend get decreased for bariatric surgery

Even if your policy covers bariatric surgical treatment coverage, brace yourself for a possibly long claims process. At best, you’ll need piles of documentation to present the surgical procedure is medically crucial for you.

Or you might run into big roadblocks. Because that CIGNA, the main reason for denials is that the betterworld2016.orgr doesn’t believe the member met the necessary criteria. In other instances, one employer may not include bariatric surgical procedure in that is plan.

If your setup doesn’t exclude coverage and also you’re denied, appeal it. Friend will probably need to administer further documentation the your require for the surgery as median necessary.

All health insurance plan should have a clear appeals process. Find out what it is and follow directions. You may only have a limited time indigenous the date you to be denied or had the procedure to obtain an very nice one underway, possibly only 60 days. Depending on your plan’s procedure, you might have to start with a phone call complaint and then relocate to a written appeal.

CIGNA claimed if a customer has actually coverage, yet medical requirement was not met and a denial was issued, a medical necessity appeal is easily accessible to the member or provider. The denial letter would provide the call information and also instructions come initiate the appeal.

If she thinking around appealing:

A good place to begin is her company’s human being resources department if your insurance is v your employer. HR can check to watch whether the plan actually consist of the surgery and also could contact the insurance money company.If you go with with the appeal, talk to her physician and collect any kind of information the will aid your case. Because that instance, asking your doctor for a letter around why the surgery is needed. Part bariatric surgeons even have “”appeals experts”” on employee that have actually experience in getting cases paid after ~ denial. Collect any type of medical records that may help. Think around your family’s medical history.Craft a letter concentrated on the decision and also why the betterworld2016.orgr need to reconsider. Save it to the facts. Don’t obtain into any type of emotional factors why the betterworld2016.orgr need to approve.Keep meticulous documents of your call with the betterworld2016.orgr and also your appeal.If it’s refuse again, check out if there’s a second appeal process or an exterior appeal.If you still get denied, call your state room of Insurance. The departments have staff human being who assist consumers v denials.

If you’ve tried everything and also you’re still acquiring denied, there space a few other options:

If your HMO plan doesn’t cover excessive weight surgery, readjust to a PPO setup at open up enrollment if the PPO arrangement covers it.Change to your spouse’s plan if it provides coverage.Get a new job. Certain big employers covering weight-loss surgical procedure as a commitment to employee health.Consider paying out-of-pocket and ask your surgeon’s office around payment plans. Follow to the ASMBS, there are additionally loans available.

Perugini had actually some advice because that those top top the fence.

“Bariatric surgical treatment is a powerful tool. The greatest piece of advice i can provide is that long-term success is as result of healthy habits. We all need to employ healthy habits. This goes for patients and for practitioners that work in the load center. We require to arrangement well to eat regular meals. We must eat great quality food. We need to be active.

See more: Actors With Black Hair And Green Eyes, Handsome Actors, 22 Gorgeous Green

“However, i feel the most essential thing around making healthy behavior a lasting part of our lives is the they need to feel good. We, together humans, carry out not carry out well v deprivation. We should have the ability to savor our meals. Exercise should be an endure that renders us feel great and that we look forward to. And if and when life provides us an especially stressful challenges, it help to have actually a support device to count on,”” that said.