Most insurance plans require that medical necessity be demonstrated before coverage is granted for weight-loss surgery. This means that in addition to your consultation with them, you'll need to provide evidence that bariatric surgery is necessary for each patient.
Qualifying Criteria for Bariatric Surgery
Your patient may be a candidate for bariatric surgery if they meet the following criteria: BMI of 35 to 39.9, with two or more comorbidities, such as diabetes, hypertension, sleep apnea or heart disease. BMI of 40 or more, with or without comorbidities.
Medical guidelines
The surgery may also be an option for an adult who meets these three conditions: BMI of 35 or higher. At least one obesity-related medical condition. At least six months of supervised weight-loss attempts.
Payment may be denied because there may be a specific exclusion in your policy for obesity surgery or "treatment of obesity." Such an exclusion can often be appealed when the surgical treatment is recommended by your surgeon or referring physician as the best therapy to relieve life-threatening obesity-related health ...
To qualify for weight loss surgery, you must demonstrate a commitment toward a healthy lifestyle. This commitment includes working to change your eating and exercise habits. We help you set realistic goals. Making steady progress toward these goals can help you qualify for surgery.
Fortunately, California is one of 23 states that require individual, family, and small group insurance plans to cover bariatric surgery through the Affordable Care Act. Most people can obtain coverage for bariatric procedures through their PPO or Medicare.
In practical terms, a person weighing 200 lbs could qualify for gastric bypass if their BMI meets the criteria used for surgery. For a shorter individual, 200 lbs might put them in the high-30s BMI (which, with health issues, meets criteria).
A body mass index (BMI) of 30 or higher, or 27 or higher if the individual has weight-related health problems, is generally required for Ozempic® qualification.
In general, BCBS plans typically cover bariatric surgery for people who meet certain medical criteria, such as: Body mass index (BMI) of 40 or higher, or a BMI of 35 or higher with one or more obesity-related comorbidities, such as type 2 diabetes or high blood pressure.
You are addicted to alcohol or drugs. You are under 18 years of age. You have an infection anywhere in your body or one that could contaminate the surgical area. You are on chronic, long-term steroid treatment.
Many insurance companies require a set period of MWM (typically 4–6 months) as prerequisite for approval for bariatric surgery. The justification is presumably to enhance postoperative weight loss outcomes and ensure dietary compliance.
While the $25 Wegovy savings offer is no longer available, there is still a Wegovy Savings Program. However, the details have changed as of January 2025. Depending on your insurance provider and coverage, you may pay as little as $0 per month for Wegovy, up to a maximum of $650 per month.
An analysis of 143 studies revealed that phentermine-topiramate and GLP-1 receptor agonists (like liraglutide and semaglutide) are among the most effective medications for reducing weight in people with obesity. The typical body weight reduction with these medications is 6% to 11%.
Ozempic at Walmart typically costs between $900 and $1,000 for a one-month supply, but this can vary. Several key factors influence the price range: Dosage: Different doses, like 0.25 mg or 1 mg, have different costs.
If you do not have health insurance, or if your insurer will not cover weight loss surgery, talk to your doctor and your surgeon about financing plans. Check on the interest rate, and make sure you are OK with all of the terms.
Be open about your struggle to afford the procedure and see what options might be available to you. Even if the hospital can't help, it may be able to refer you to a local nonprofit that can. Negotiate medical bills after the surgery. Most billing offices are willing to set up payment arrangements with patients.
Government aid for weight loss surgery costs
The federal government can help cover the weight loss surgery cost for qualified patients under the Medicaid and Medicare programs. Both programs have eligibility restrictions, an application process, and a waiting period.
Most patients can be pre-approved for bariatric surgery within a matter of 90 days/12 weeks (with consecutive office visits throughout) if there are no medical weight loss program requirements, but there is no guarantee.
Background: Many patients who seek weight loss surgery are denied an operation because of insurance barriers, psychological concerns, and poor medical fitness for surgery.
She encourages people to consider undergoing bariatric surgery sooner rather than later. “People in their 20s, 30s and 40s will get more time out of the benefits of weight loss surgery,” explained Dr. Wischmeyer.