Weight loss surgeries have been increasing in popularity due to the rise in obesity rates worldwide. Not only does obesity affect a person’s physical health, but it can also cause various psychological and social issues.

Hence, many people turn to these surgeries to shed some weight and improve their overall health. However, not everyone can afford to pay for these surgeries out of pocket, which is why they rely on insurance policies to cover the costs. But, when does insurance cover weight loss surgeries?.

Insurance Policies that Cover Weight Loss Surgeries

Contrary to what some people might believe, not all insurance policies cover weight loss surgeries. For example, most standard health insurance plans do not include these procedures in their coverage.

However, some policies do cover these surgeries under specific circumstances. Here are some examples:.

1. Employer-Based Health Insurance Plans

Employer-based health insurance programs are more likely to cover weight loss surgeries compared to standard plans. The primary reason for this is that these policies are usually customizable and offer more benefits than standard plans.

Generally, these policies define certain requirements that a person must meet to be eligible for weight loss surgeries. These requirements may include having a BMI of above 35, having co-morbidities such as sleep apnea, type 2 diabetes, or hypertension, and having tried to lose weight through non-surgical methods unsuccessfully.

2. Medicare and Medicaid

For those who are aged 65 or older or have certain disabilities, Medicare may cover some weight loss surgeries such as gastric bypass surgery, laparoscopic sleeve gastrectomy, and gastric banding.

However, the conditions under which these procedures are covered vary, and eligibility is determined on a case-by-case basis. On the other hand, Medicaid policies may cover weight loss surgeries for individuals who meet specific age, BMI, and medical requirements. Typically, these policies cover gastric bypass surgery and lap band surgery.

3. Self-Purchased Private Health Insurance Plans

Individuals who purchase private health insurance plans are more likely to have weight loss surgeries covered than those with standard health insurance plans.

However, it is essential to read the policy’s fine print to determine whether or not these procedures are covered and to what extent.

Factors that Affect Coverage of Weight Loss Surgeries

The coverage of weight loss surgeries under insurance policies is not standard, and different providers can have different requirements. Here are some factors that play a role in determining coverage:.

1. BMI

Body Mass Index (BMI) is one of the primary factors that insurance providers use to determine whether someone is eligible for weight loss surgeries. Typically, individuals with a BMI of 35 or higher are considered eligible for these procedures.

2. Proof of Non-Surgical Weight Loss Attempts

Insurance companies typically require their clients to try non-surgical weight loss methods such as physical exercise and dieting before resorting to surgery.

Clients are usually required to keep records of their efforts, including appointments with nutritionists or personal trainers.

3. Co-morbidities and Health Issues

Insurance providers might cover weight loss surgery under specific circumstances, such as when the patient has medical conditions such as hypertension, diabetes, or sleep apnea.

4. Age

Medicaid, for example, may cover weight loss surgeries for individuals aged 18 and above who meet specific criteria.

Types of Weight Loss Surgeries Covered by Insurance Policies

Insurance providers usually cover several types of weight loss surgeries, including:.

1. Gastric Bypass Surgery

Also known as Roux-en-Y gastric bypass, this surgery involves reducing the stomach’s size and binding a portion of the small intestine to that small stomach pouch.

This procedure aims to limit the amount of food a person can eat and reduce calorie absorption, leading to weight loss.

2. Gastric Banding

Also known as Lap-Band, this surgery involves placing a silicone band around the stomach to limit the amount of food a person can eat. The band is adjustable so that the patient can change it to suit their weight loss needs.

3. Sleeve Gastrectomy

This surgery involves removing a portion of the stomach and creating a tubular-shaped stomach “sleeve”. The goal is to reduce the amount of food the patient can eat and create a hormonal response that reduces hunger.

When Insurance Policies Do Not Cover Weight Loss Surgery

Insurance policies may not cover weight loss surgeries under specific circumstances, including when the patient:.

1. Does Not Meet BMI Requirements

Patients whose BMI is below 35 may not be eligible for weight loss surgeries.

2. Has a History of Drug or Alcohol Addiction

Insurance providers may not cover weight loss surgeries for patients with a history of substance abuse or addiction.

3. Has Untreated Psychiatric Issues

Patients with underlying psychiatric issues such as depression or anxiety disorder may have difficulty adjusting to life after surgery, and insurance providers may not cover these procedures.

Conclusion

Weight loss surgeries can be costly, and insurance plans can be a way to cover some of these expenses. However, not all insurance policies include weight loss surgeries in their benefits.

It is essential to read the policy’s fine print carefully and check eligibility requirements before resorting to surgery. Additionally, patients should have realistic expectations of what these surgeries can achieve and maintain a healthy lifestyle after the procedure to maximize its benefits.