Is Weight Loss Surgery Covered by Insurance? BMI Requirement Explained

Is weight loss surgery covered by insurance?¹⁷

While weight loss surgery may be covered by insurance, factors such as the type of surgery, insurance plan (HMO, PPO, Medicaid etc.), and BMI requirements should be reviewed to determine if the surgery is covered for a given individual and their particular circumstances. 

With that being said, the information below goes over the various bariatric surgeries, if different insurance plan covers them, the qualifications for surgery and potential cost — although different insurance plans will have different deductibles, copays, and out of pocket maximums that vary between in-network and out-of-network providers. 

So before thinking “I will never lose weight,” see if you can get insurance to cover weight loss surgery and how to go about it. 

When Is Weight Loss Surgery Covered by Insurance? 

Bariatric surgery is the umbrella term for a variety of different weight loss surgeries. In order for someone to be a candidate for weight loss surgery there are a few different things that must be aligned. 

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BMI: Individuals with a BMI over 40 would qualify for surgery based on their BMI and weight alone. If someone also struggles with obesity-related illnesses such as diabetes, hypertension, or sleep apnea their BMI can be 35 to qualify for surgery. 

Insurance Types: There are a variety of different types of insurance companies and policies and most of the time there are a lot of options for health insurance that cover bariatric surgery, at least a portion of it if the requirements have been met. Here are the top 4 different types of insurance available in the United States. 

• Preferred Provider Organization (PPO): This is a type of insurance plan that has contracts with different medical providers such as hospitals and doctors.¹ From that, a network is created including the list of participating providers.

Someone will pay less for using providers in the insurance plan’s network. Individuals on this plan will have more flexibility and could choose to see anyone they want but will face additional charges if the doctor is outside of the network.

PPO plans are often more expensive per month but offer a lot of flexibility in what specialists and doctors can be seen.

• Health Maintenance Organization (HMO): A HMO insurance plan limits coverage to only doctors who are contracted with the HMO.² Out-of-network care will not be covered unless there is an emergency. In order to be eligible for HMO services typically someone will need to live or work in a specific service area. HMO plans typically will have a lower monthly payment but much less flexibility.
• Medicare: Medicare is federally backed health insurance for individuals over 65 and younger individuals with specific disabilities.³ 
• Medicaid: This insurance program is for low-income families, children, pregnant women, the elderly, and people with disability and provides free or low-cost health insurance coverage.⁴ 

Types of Surgeries: In the United States there are three weight loss surgeries that are most common. In order to qualify for each of these surgeries there are specific qualifications that must be met and other weight loss interventions, such as diet changes and exercise, must have been tried before resorting to surgery. 

Additionally, often someone will talk with a psychotherapist and dietitian before finalizing surgery details. 

• Gastric Sleeve: In this surgery, most of the stomach is removed and only a small banana-shaped section is left and closed with staples.⁵ The purpose of this surgery is to reduce the size of the stomach which will make someone feel full quicker. 

It is possible this surgery may impact gut hormones and bacteria. This surgery is irreversible but has been shown to lead to greater weight loss compared to a gastric band.

• Gastric Bypass: This surgery has three parts, starting with the doctor stapling the stomach to create a small pouch at the top. This is similar to the gastric sleeve with the intent to make the stomach smaller helping someone feel full faster.

Then the surgeon divides the small intestine into two parts, connecting the lower part to the smaller stomach pouch. 

Finally, the upper part of the small intestine piece is connected to a location farther down on the small intestine. By doing this, digestive juices in the stomach flow from the small intestine to the lower part of the small intestine. The bypass will also impact appetite and metabolism because of the changes to gut health and hormones. This surgery is difficult to reverse but can be done if medically needed.

• Adjustable Gastric Band: Commonly referred to as lap-band surgery this is the one bariatric surgery that is more easily reversible. The doctor will place a ring that has an inner inflatable band around the top of the stomach to create a small pouch, similar to the outcome of the gastric bypass. 

Like with the other surgeries, the goal of this is to make someone feel full quicker. The surgeon can adjust and resize the band by injecting or removing saline solution through a port that is placed under the skin.

This surgery is actually performed less often compared to gastric sleeves and bypasses because there is a higher risk for complications, the need for reversals, and less weight loss reported.⁶ 

There are also 2 additional weight loss surgeries that are less commonly performed. 

• Biliopancreatic diversion With Duodenal Switch: This surgery changes the size of the stomach and changes the length of the small intestine.⁷ By doing so it limits how much food can be eaten, digested, and absorbed.

This surgery does require someone to take vitamin and mineral supplements for life and is a higher-risk procedure with the potential for more long-term health issues. 

• Single Anastomosis Duodeno-Ileal Bypass With Sleeve Gastrectomy: This is a newer operation that is continuing to get more attention by research because it has been shown to have lower complication rates while also showing significant weight loss and low weight regain.⁸

Does Medicare or Medicaid Cover Weight Loss Surgery?

When wondering is weight loss surgery covered by insurance, someone may be curious to also know if Medicare and Medicaid will cover any of those expenses. Medicare will cover some weight loss surgeries as long as certain conditions are met.⁹

Unfortunately, it is to predict how much Medicare will cover because each situation is so individualized. 

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Medicare does have different coverage costs for inpatient vs outpatient procedures so knowing which you would be would help someone estimate their costs. Additionally, it’s possible to log in to the Medicare account to see if the deductible has been met because Medicare will not be able to pay for any procedures until the deductible has been reached. 

Because Medicaid is more geared towards children and young adults Medicaid does have some additional requirements to qualify for coverage of weight loss surgery as this surgery is typically geared towards adults. Females must be at least 13 years old and males at least 15.

If the individual is under 21, the BMI must be over 40 and they must also have at least one obesity-related illness such as sleep apnea, high blood pressure or cholesterol, or diabetes. 

Does Insurance Cover Every Type of Weight Loss Surgery or Bariatric Surgery? What Are the Requirements? 

A lot of PPOs, select HMO insurance policies, Medicaid, and Medicare recognize the seriousness obesity can have on someone’s health and will cover costs related to the various bariatric surgeries including gastric sleeve, lap band, and gastric bypass. In order for insurance to be able to cover the surgery there is a list of qualifications someone must meet. 

1. BMI Qualification: The individual’s BMI must have at least 40 or 35 with an obesity-related condition such as cardiovascular disease, type 2 diabetes, high blood pressure, and more. 

2. Weight Loss Program History: Documentation that someone participated in a weight loss program for at least 3-6 months.

3. Preoperative Counseling: All the different types of weight loss surgery do require significant lifestyle changes post-surgery so it’s important to have counsel from a nutritionist or dietitian and psychologist to make sure the patient is fit and ready for those changes. This is also a very important time to ensure they fully understand all the associated risks and changes that will have to happen.

This preoperative counseling also aims to understand the person’s reason behind the surgery and what their current lifestyles are to ensure they are a good candidate for the procedure. 

Another important layer to consider when questioning is weight loss surgery covered by insurance is there are 23 states that require all individual, family, and small group insurance plans to cover weight loss surgery. The 23 states are Arizona, California, Colorado, Delaware, Hawaii, Illinois, Iowa, Maine, Maryland, Massachusetts, Michigan, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia, and Wyoming. 

Georgia, Indiana, and Virginia are the 3 states that offer weight loss surgery coverage but not all policies are required to cover it. 

How Much Does Weight Loss Surgery Cost?

Weight loss surgery costs before insurance can be a hefty bill with the average costs being between $7,400 and $33,000 depending on which type of procedure is done and location. While weight loss surgery is covered by insurance, or at least typically will cover a portion of the surgery, someone may also be curious to know what self-pay prices would look like. 

Here is a breakdown of what the average out-of-pocket costs could look like for each bariatric surgery.

Gastric Sleeve Surgery Cost

Gastric sleeve cost can also vary greatly based on location but the average cost for this surgery is just under $10,000. While this estimate does cover all the basic fees such as anesthesia, the hospital and surgeon fees, and pre and postoperative care, this amount could increase greatly based on the amount of time spent in the hospital and if any additional support is needed.

The gastric sleeve cost with insurance also can vary significantly based on the type of insurance but it’s possible for insurance to cover all or a portion of the procedure, especially if the need for the surgery is related to a medical condition caused by obesity. 

Lap Band Surgery Cost

The lap band surgery cost can vary significantly with the average costs ranging from $9,000 and $18,000. These prices will vary depending on location, as well as the patient’s current health, and which hospital and surgeon will do the procedure.

Having the procedure at a surgical center instead of a hospital is an easy way to really cut down on the overall price. 

Gastric Bypass Surgery Cost

Each patient situation is unique so the prices will vary based on individuals and locations but the average cost for a gastric bypass in the U.S. is between $20,000 and $25,000. 

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While gastric bypass surgery does have one of the higher upfront surgical costs, research has shown that over a 5-year period, this weight loss surgery is the most cost-effective treatment.¹⁰

Duodenal Switch Surgery Cost

While specific prices may vary depending on the location, the average price for this procedure without insurance is $23,000 but that price does jump up to $30,000 in some areas. While this is an expensive bill these costs typically do cover everything from the preoperative care, anesthesia and surgeon fees, pre and post-operation education, and the hospital stay. 

Single Anastomosis Duodeno-Ileal Bypass With Sleeve Gastrectomy Surgery Cost

The average price for this procedure is $20,060. This estimate also does include most of the fees a patient would see throughout this weight loss surgery journey from pre and postoperative care and education, anesthesia, and the time spent at the hospital.

Alternatives to Weight Loss Surgery

Alongside wondering is weight loss surgery covered by insurance, someone may also be curious to know what other alternatives there are to surgery. All of the available weight loss surgeries do come with potential risks, significant lifestyle changes, and the need to recover from a major procedure. 

Sometimes weight loss surgery is the best option and it’s important to always discuss what would be best for your individual situation with your healthcare team. But other times different interventions can be successful and help someone lose the weight they need to lose.
Here are a few weight loss surgery alternatives someone could try out.

1. Weight Loss Pills: There are 6 weight loss drugs that have been approved by the FDA as well as a huge list of over-the-counter weight management pills.¹¹ Here are some over-the-counter diet pills that actually work.

Alli is the only FDA-approved over-the-counter so it could potentially be the best weight loss pills. 

Additionally, research has shown that the most effective drugs for weight loss were phentermine and topiramate, pramlintide, naltrexone, bupropion, and liraglutide.¹² When seeking prescription weight loss pills knowing how to ask your doctor for weight loss pills can be helpful.

2. Medically Supervised Diet: When someone is struggling to find different weight loss solutions and it seems like nothing is working, turning to a doctor or another medical professional to help them make changes to their diet could be another option to try out before giving up on losing weight. These diets sometimes will consist of liquid meals and could give someone the guidance they need to jumpstart weight loss.

3. Exercise: While exercise may not be an option for everyone, especially depending on any other health problems or mobility issues someone may have, this could be a good option to try out. Starting out small could also make things feel more manageable and less overwhelming.

Source: Julia Larson via Canva.com¹⁶

Seeking help from a personal trainer who has experience with weight loss could be beneficial as well.

Making the decision to have weight loss surgery can be tough as the procedure can come with potential risks and big lifestyle changes but it can also help someone lose a significant amount of weight to improve their overall health. As the surgeries can become very pricey, it’s great to know that is weight loss surgery covered by insurance is a yes as long as certain qualifications have been met.

Frequently Asked Questions About Is Weight Loss Surgery Covered by Insurance?