Posted - September 10, 2018

Health Insurance Benefits and Weight Loss Surgery

Health Insurance Benefits

Last week, we talked about investing in yourself. Having weight-loss surgery is one way to invest in yourself, but you don’t have to be the sole contributor. Most insurance companies today provide coverage for weight-loss surgery, but there is fine print. If you do your research, you can balance the cost using your health insurance benefits. In this post, we’ll outline some ways to make the most of your 2018 health insurance benefits.

Determine what is and is not covered in your health insurance benefits

Not all procedures are covered, so it’s important to confirm what your plan includes and what it doesn’t.

For example, Blue Cross Blue Shield (BCBS), one of the largest providers in Texas, covers bariatric surgical procedures. However, not all types of procedures are included. Once you determine what kind of procedure you need, find out if it’s eligible for coverage.

Covered procedures include:

Non-covered procedures include:

  • Mini- and long-limb gastric bypass
  • Vertical banded gastroplasty
  • NOTES (natural orifice transluminal endoscopic surgery)
  • Transoral gastroplasty (a.k.a. “TOGA”)

Additionally, most health insurance benefits won’t cover things like post-operative cosmetic procedures, costs associated with your diet and exercise plan, etc.

Call us or schedule an appointment to discuss your provider’s benefits.

Make sure you meet all criteria

To be eligible for coverage, insurance companies require that prospective patients meet certain criteria, so it’s important to check with your insurance company prior to signing up for any procedures.

In order to qualify for coverage with BCBSTX, you must have a diagnosis of morbid obesity and be able to present the following:

  • Documentation from your surgeon attesting to the fact that you are a fully grown, legal adult, and that you understand what to expect post-op.
  • An evaluation from a licensed weight-loss counselor, psychiatrist, or psychologist received within the previous 12 months.

(Note that even if you meet the above criteria, there are certain other excluding factors to consider—certain medical illnesses, being pregnant or lactating, and having certain types of insurance policies may negate your eligibility for coverage.)

Have a post-op plan

Weight-loss surgery can change, maybe even save, your life, but unfortunately it isn’t a cure-all. Your procedure will jumpstart your weight loss, but to keep that momentum going and ensure the benefits of the surgery last, you’ll need a nutrition and exercise plan.

Work with your doctor to develop a post-operative plan that you can maintain and build upon. Make sure you stick with it—revisional surgery, if needed, is only considered for coverage if you are able to show that you adhered to a post-operative diet and exercise routine.

Should you have questions or need guidance in anything discussed above, don’t be afraid to ask your doctor for help. Your doctor is your health advocate and insurance resource; they will be familiar with—and can help you navigate—the intricacies of your health insurance benefits and requirements so that you can get your procedure covered. It also helps if you can gather any records from previous doctor visits and treatments received for health conditions that are related to your weight—you may be able to show that the cost of the surgery justifies the long-term cost of care due to obesity-related health problems.

In the event your request for coverage is denied, know that you can appeal, and if all else fails or your procedure isn’t fully covered, your doctor can work with you on a payment plan. But let nothing stop you on your quest for better health and a better life.

Learn more about Dr. Ayoola and Weight Loss Specialists of North Texas.


ATTENTION patients of Dr. Al-Kalla

Dr. Al-Kalla will be leaving Weight Loss Specialists of North Texas at the end of July. If you would like continue as his patient, please let us know and we can assist in getting your medical records transferred.

You may also choose to stay with Weight Loss Specialists of North Texas and we’ll gladly transfer your care to another provider on staff.

Thank you.