There is presently no information on whether or not the Orbera balloon is covered by insurance. If you are considering this weight loss procedure, however, you should contact your insurance company directly.
Will insurance ever cover gastric balloon?
The average cost of a gastric balloon is $8,150. Although your doctor may be able to get part of the costs paid, it is usually not covered by insurance.
Tax deductions and other doctor-specific discounts can often minimize the cost.
This page will tell you all you need to know about the gastric balloon treatment and how to pay for it.
How do you qualify for a gastric balloon?
Who is it for?
- You’re willing to make healthy lifestyle adjustments, see a doctor on a regular basis, and take part in behavioral therapy.
How much does the balloon pill cost?
Kimmy wants to shed 60 pounds. She claimed that gastric bypass and lap-band surgery were not the best solutions for her.
“I feel like cutting your stomach isn’t really the issue,” Kimmy continued, pointing to her mouth.
However, Kimmy’s dilemma is that the medication isn’t available in the US because it hasn’t been approved by the US Food and Drug Administration. It’s available at a Tijuana, Mexico-based weight-loss facility.
The Obalon pill is provided by Dr. Ariel Ortiz, a physician from Tijuana who was compensated by Obalon to help research the capsule. Ortiz goes from his home in San Diego to his clinic, The Obesity Control Center in Tijuana, every day.
Dr. Ortiz’s facility in Mexico offers a variety of plastic surgery operations at a fraction of the cost of similar procedures in the United States.
Thousands of Americans flock to Mexico in quest of low-cost medical care because of his low charges. Ortiz claims that 70% of his clinic’s patients are Americans, and that his staff has received more than 100 calls from patients interested in learning more about the “balloon pill,” the majority of whom are also Americans.
Another alternative for those wanting to shed weight, according to Ortiz, is the balloon pill.
“We’re going to call it an option for some,” he said, referring to people who are terrified of surgery or who don’t fully qualify for it. “It will undoubtedly be a first step for those who are exceedingly overweight and, let’s say, have a very significant surgical risk.” I’m not willing to take that chance.”
So far, the outcomes have been outstanding. Patients have lost 30 pounds in 12 weeks, according to Dr. Ortiz.
Obalon is so new that there is no agreement in the medical community in the United States yet, but there is plenty of curiosity.
While bariatric surgery should be a last resort, Dr. David Katz, who teaches weight management at Yale-Griffin Prevention Research Center in Derby, Connecticut, said his concern about Obalon is the user’s ability to maintain weight loss once the balloon is removed.
“The stomach is a hormone-producing organ, and bariatric surgery affects the production of a hormone called ghrelin, which is one of the procedure’s effects,” he explained.
“Does the balloon have that effect?” Will it be able to compete with the impacts of surgery? Because the surgery’s effects are usually permanent, and if you have a balloon inserted in your stomach to make you eat less and lose weight, are you then reliant on that balloon for the rest of your life?”
Patients come to Ortiz not only for the Obalon capsule, but also for other treatments that are allowed in the US but less expensive in Mexico, such as cosmetic and gastric-bypass procedures, according to Ortiz. The balloon pill costs around $4,000, which is a fraction of the cost of gastric bypass surgery and is far less invasive.
“We use the exact same equipment, instrumentation, and standards as are used in the United States without the overhead expenditures of operating in the United States with all that red tape,” Ortiz explained.
After three months, the pill is meant to be discontinued. Kimmy and Daisy Markley both dropped weight in the first 30 days, with Markley losing 10 pounds and Kimmy losing 22 pounds.
Both women are halfway to their targets, but the main test will be if they can keep the weight off when the balloons come out in two months.
What weight loss surgery is covered by insurance?
Bariatric (weight-loss) surgery is covered by all health funds, but you must have a high level of coverage. Simply contact your health-care provider and provide the following ‘item numbers’: 31569 Gastric Band, 31575 Gastric Sleeve, 31572 Gastric Bypass That’s all there is to it!
What if your insurance doesn’t cover bariatric surgery?
After you’ve weighed your alternatives and decided that bariatric surgery is the best option for you, you’ll want to know how you’ll pay for it. Many insurance companies acknowledge the importance of obesity and its health repercussions, and will pay for weight loss procedures if you meet plan-specific eligibility requirements.
How to verify your own benefits
Although the staff at your surgeon’s office will verify your benefits as a courtesy, it’s a good idea to call your insurance carrier to confirm coverage and restrictions. You can also read the coverage documentation that your employer and/or insurance company have issued to you.
You’ll want to know if bariatric surgery is covered; if it isn’t, it’ll most likely be included under “obesity” or “weight reduction surgery” in the plan’s exclusions. Bariatric surgery is commonly described as being covered if it is medically required, but this is only partially accurate because it must also be a covered benefit.
You’ll want to know what’s required once you’ve confirmed that your plan covers bariatric surgery. Each plan has its own set of criteria and regulations for determining medical necessity to your insurance carrier’s satisfaction. Although your carrier’s medical policy is the most typical place to obtain benefit criteria, your employer may have an addendum document (“summary plan document/description”) that explains extra or other requirements for particular treatments. Because the requirements of the medical policy are often superseded by a summary plan document, it’s crucial to know if an addition like this applies.
Medical necessity vs. coverage exclusions
Despite the fact that you may meet basic and widely accepted medical necessity requirements, your insurance company is not compelled to cover bariatric surgery. Your insurance will not consider you for coverage if weight loss surgical services are designated as an exclusion, regardless of your BMI or concomitant conditions. The denial rationale does not imply that surgery is not medically required, but rather that they do not give this form of coverage, for which there is no appeals process.
Cash paying for surgery
There are alternative solutions open to you if your insurance does not cover bariatric surgery. Consultations, nutritional counseling, pre- and post-operative tests, labs, and follow-up visits may be covered depending on the plan language, but surgery is not. Verifying your benefits will assist us in estimating potential costs for you during your appointment.
How to meet insurance criteria
You’ll meet with a surgeon for a consultation once your benefits have been validated. Your height, weight, and BMI will be recorded, as well as any concomitant conditions and previous unsuccessful attempts at non-surgical weight loss. If your plan calls for a medically supervised weight loss program, you’ll meet with a nutritionist on a monthly basis for the duration of your treatment.
Because a psychological clearance is the most prevalent insurance criterion, you should make an appointment with a mental health specialist who will assess your candidacy for bariatric surgery. It’s crucial to rule out psychological issues, any type of disordered eating, a lack of competence to provide informed consent, and a failure to follow pre- and post-surgical instructions.
Insurance authorization process
The authorisation process can commence if all pre-surgical and insurance requirements have been satisfied. Your pertinent medical records will be compiled and sent to the clinical review department of your insurance company. A determination can take up to four weeks, but it is more common to receive one in two weeks. You’ll be advised of the approval or denial once we hear from your insurer. Surgery can be planned or confirmed once you’ve gotten approval.
If your operation is denied, we will examine the decision and follow the measures provided by your insurance company. Denials can occur for a variety of reasons, including a lack of paperwork or a lack of agreement on criteria that are ambiguous or open to interpretation.
Appeals
Because appeals deadlines may be approaching quickly, it’s critical to properly evaluate denials.
As a first step in this procedure, a peer-to-peer option is usually provided. A peer-to-peer meeting is a prearranged meeting between your surgeon and the medical director of the insurance company to address the denial. When this conference is feasible, it’s quite beneficial since we can get precise input from a reviewing authority about what additional the insurance company expects us to provide or what they want you to accomplish in order to qualify. At the time of this debate, the rejection may be affirmed or reversed, but it’s usually just a tool for moving forward with the appeal.
If an appeal is necessary, we will obtain any additional documentation that was previously overlooked. If more tests or office visits are needed, they should be planned as quickly as possible to ensure that they are completed before the appeal time expires.
There could be several stages to the appeals process. A second- or third-level appeal can be requested if necessary, with the final step typically including submission to an outside party for review. Because external review organizations are not linked with our office or your insurance provider, they can conduct an unbiased assessment of your clinical documentation.
What can I do to ensure approval?
A patient health history questionnaire will be given to you prior to your session. Because it will be translated into your medical record, which will be evaluated by the insurance provider, it is critical that you fill this out entirely and truthfully.
Bring a copy of any paperwork (medical chart notes, personal records, logs, or receipts) from past weight loss attempts, whether by diet, exercise, or medical supervision, to be reviewed and scanned into your chart.
If you’ve had a previous weight reduction treatment, you should get copies of your operative report, as well as pre- and post-surgical visits, to demonstrate your commitment to follow-up and adherence to any suggestions provided by your previous practitioner.
The single most important thing a patient can do to increase the chances of their insurance company approving their claim is to follow the medical policy’s rules to the letter (or Summary Plan Document, if applicable). Medically supervised diets are generally need to be followed for several months and should be spread out by about 30 days. Failure to keep scheduled appointments for several months in a row will almost always result in denial, delaying surgery or forcing you to restart the prescribed regimen from the beginning.
What is the safest weight loss surgery?
Each type of bariatric surgery has advantages and disadvantages. The surgeon recommends a surgical type based on the patient’s health and needs. Although all surgeries entail some risk, restrictive surgeries are safer than restrictive/malabsorptive surgeries since they do not interfere with the digestive system permanently.
Gastric Banding
This is the simplest and safest of the bariatric procedures. However, the weight loss is less than with the other procedures. Furthermore, people who have had gastric banding are more prone to gain weight in the long run. There is reduced risk of nutrient shortage because the operation has no effect on nutrient absorption.
Sleeve Gastrectomy
For severely obese persons with other health problems, this is a generally safe and easy surgery. Weight reduction is substantial, and nutritional absorption is unaffected. This is a relatively novel technique, and the long-term benefits and hazards are currently being assessed.
Gastric Bypass
This procedure allows for rapid weight loss that lasts for up to two years. It is beneficial to patients with obesity-related illnesses who want to improve their health swiftly. It also has a solid long-term weight-loss track record. Hernias and vitamin deficits due to malabsorption are the disadvantages. Dumping syndrome occurs when food is discharged from the stomach into the intestines before being thoroughly digested.
Duodenal Switch
This surgery is more difficult and risky than the others, and it is also less common. It causes faster weight reduction, but it also increases the risk of hernias, nutrient deficit, and dumping syndrome.
Who is not a candidate for gastric balloon?
- You are reluctant or unable to adhere to a 12-month program that includes a healthy diet and activity plan, beginning with the balloon insertion and continuing for 6 months afterward.
- You use anti-inflammatories or anticoagulants, such as blood clot medications, on a prescription basis.
- You’re expecting a baby in the next six months, or you’re breastfeeding.
Is the gastric balloon worth it?
For patients with lower BMIs, gastric balloons are a viable alternative to bariatric surgery. Over the course of six months, the majority of patients lose between 20 and 50 pounds (about 10 to 20 percent of total body weight).
Gastric balloons can be beneficial, and they can be inserted in a matter of minutes without requiring surgery. They are, however, only temporary, and success requires a lifestyle change, knowledge, and support.
How much weight can I lose with gastric balloon?
Patients will not lose as much weight as they would with other surgical options because the gastric balloon is developed primarily for persons with a lower BMI. A gastric bypass patient can drop more than 100 pounds, while candidates for the gastric balloon lose 20 to 40 pounds (or 10 to 20% of their body weight) over the course of six months with the balloon in place.
Is gastric bypass covered by insurance?
Different insurance companies and policies cover different treatments, however most insurance companies will cover the major bariatric surgeries, including as gastric bypass, gastric sleeve, and gastric band, at least partially.