Weight loss surgery

Weight loss surgery is a medical procedure designed to help individuals with obesity lose significant body weight by modifying the stomach or digestive system. Major types of weight loss surgery include gastric bypass, sleeve gastrectomy, and adjustable gastric banding, each reducing stomach capacity to restrict food intake.

Most insurance providers, such as Aetna and UnitedHealthcare, require candidates to have a BMI over 40, or over 35 with related health conditions like type 2 diabetes. Insurance companies frequently mandate documented failed attempts at medically supervised weight loss programs lasting 6-12 months before approval.

Common covered expenses include hospitalization, anesthesia, surgeon’s fees, and post-operative visits if preauthorization criteria are met. Exclusions often apply for revisional surgeries unless medically necessary due to complications verified by clinical evidence, according to YourInsuranceInfo.

Prior authorization almost always requires submission of psychological evaluations and proof of long-term commitment to lifestyle changes. Out-of-pocket costs can range from $3,500 to $30,000 depending on deductible levels and coverage details.

Medicaid covers weight loss surgery in most states if strict criteria are met; Medicare covers certain procedures for qualified beneficiaries with obesity-related comorbidities. Coverage denials typically result from lack of medical necessity documentation or non-compliance with multi-disciplinary evaluation protocols mandated by insurers like Blue Cross Blue Shield.

Appeal success rates increase significantly–up to 50% in some studies–when denied applicants submit additional physician support and comprehensive clinical records during the appeals process.