Gastric Bypass Surgery – Will Insurance Cover the Cost?

Depending on the type of major medical insurance policy you
have, most insurance companies will pay for gastric bypass
surgery (also called bariatric surgery) if you meet certain
conditions. However, some insurance companies have exclusion
clauses for treating obesity. These companies refuse to cover
any treatment related to “losing weight.” They will, however,
treat the diseases caused by excessive body weight. How do I
qualify for coverage?

To qualify for coverage, gastric bypass surgery must be
considered a medical necessity. The insurance company will make
the final determination. They may rely on the information your
doctor sends to them or they may require you to be seen by a
doctor that they specify.

In either case, certain conditions must exist. Your weight
problem must present a serious risk to your life. Don’t be
surprised if they require a complete psychological evaluation in
addition to your medical records. It is no secret that people
eat too much of the wrong kinds of food for many reasons. While
genetics and metabolic rate do affect how much a person weighs,
often the primary causes of obesity are emotional and
psychological. Gastric bypass surgery will not fix these
emotional and psychological problems. In fact, if these issues
are not dealt with prior to or along with the surgery, the
patient may be more likely to experience serious complications.
For this reason, all insurance companies require both a medical
and psychological clearance before they will approve the
surgery.

Remember, insurance companies are businesses. If they think you
are a good candidate to maintain the weight loss permanently and
that the $25,000 to $50,000 dollar price tag for gastric bypass
surgery now will save them money in the long run by eliminating
payment for other weight related medical problems, they will
most likely cover the surgery.

How much will my insurance carrier cover?

If you are approved for gastric bypass surgery, your insurance
company will pay anywhere from 50 to 100 percent of the hospital
and doctor fees. Some policies will even cover in-home nursing
care after release from the hospital if it is deemed necessary
by the doctors and approved by the insurance company.

Several different expenses typically are associated with gastric
bypass surgery, such as testing to determine eligibility for
gastric bypass surgery, pre-admission testing, in-hospital
costs, surgeon and other doctor fees, and post-surgery
medication and care. Even if your insurance company will not
cover the actual procedure, they may cover one or more of the
other costs related to your gastric bypass surgery.

How can I make up the difference?

Your surgical center should be able to help you determine what
will and will not be covered by your specific policy. In
addition, many surgical centers offer low-interest, long-term
loans if you are not approved by the insurance company, do not
have medical insurance, or have high co-payments.

Since 2000, the total cost of all medically necessary weight
loss treatment has been considered a deductible medical expense
for income tax purposes. Those tax deductions can help you pay
for at least part of the cost of your gastric bypass surgery or
help you get back your co-payment for the surgery. Under the
Internal Revenue code, treatment for weight loss includes
behavioral counseling, nutritional counseling, prescriptions,
and gastric bypass surgery if they are undertaken to treat or
prevent specific diseases caused by excessive body weight.

This article provides an overview of health issues related to
gastric bypass surgery and is not intended to replace the advice
of a medical practitioner. Please consult your doctor prior to
making any major medical decisions.

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