Certain commodities and services are included in all health plans available on the Health Insurance Marketplace. These services are referred to as Essential Health Benefits.
Emergency services, outpatient or ambulatory services, preventive and wellness services, maternity and newborn care, pediatric services, mental health and substance abuse services, laboratory services, prescription drugs, therapy services (such as physical therapy) and devices, and hospitalization are all included in every Ambetter insurance plan.
Some of the information on this page came from https://www.healthcare.gov/.
How overweight do you have to be for insurance to cover bariatric surgery?
Your body mass index, a numerical number of your weight in relation to your height, plays a role in determining your eligibility for bariatric surgery. The BMI range of 18-24.9 is seen as ideal. A BMI of 40 or higher is considered morbid obesity.
If you have a BMI of 35-39 with particular serious health concerns like Type 2 diabetes, sleep apnea, or high blood pressure, you may be a candidate for bariatric surgery. A BMI of 40 or more is also a requirement.
Is bariatric surgery is always covered by medical insurance?
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.
How long does it take for insurance to approve weight loss surgery?
A growing number of states have approved legislation requiring insurance companies to provide weight-loss surgery for people who fulfill the NIH surgical requirements. While weight-loss surgery is commonly covered by insurance, the approval process can be lengthy and confusing. Working with your surgeon and other professionals gives you the best chance of getting insurance coverage approved.
Steps to obtain insurance coverage for bariatric surgery:
- Most insurance companies are aware of the health risks associated with obesity and will cover the costs of surgical weight loss in qualified patients. Every insurance plan, however, is unique.
- We begin the process of obtaining insurance authorization once you have completed our preparatory program, satisfied all of your insurance company’s requirements, and the surgeon has cleared you for surgery. We start by submitting your medical records to your insurance company, requesting that they fund the procedure. The insurance company may take two to four weeks to react with a decision.
- Once we obtain permission or refusal from the insurance carrier, we will contact you. If the coverage is accepted, the patient is given a surgery date and a pre-op appointment. If coverage is refused, we investigate the cause for the decision and file an appeal with the insurance carrier.
Which Ambetter plan is best?
Ambetter offers Marketplace insurance products in three tiers: Gold, Silver, and Bronze.
- Ambetter Secure Care is a Gold-tiered plan, which means it has the most expensive monthly premium payments.
- Ambetter Balanced Care is the most cost-effective plan, according to Ambetter. This Silver-tiered plan has low out-of-pocket charges and low monthly premium payments. It’s the ideal “in the center” strategy.
- The monthly premium payment for Ambetter Essential Care is the cheapest. This is a suitable option for folks who don’t plan to need medical treatment frequently, as it is a Bronze-tiered option. To compensate for the low monthly premium, this plan has the greatest out-of-pocket payments.
Ambetter’s coverage options are, on the whole, very conventional. It does, however, provide the option of selecting a plan that includes vision and adult dental care, unlike some of its competitors. Choosing a plan like this is a terrific way to acquire comprehensive coverage from a single insurer.
Does Ambetter cover MRI scans?
For CT/CTA, MRI/MRA, PET, CCTA, Nuclear Cardiology/MPI, Echocardiography, and Stress Echo imaging treatments, Ambetter from Magnolia Health members will have access to NIA’s Free-Standing Imaging Facilities as well as Ambetter from Magnolia Health’s in-office doctors and hospitals.
How do I get approved for weight-loss surgery?
You must meet the following criteria to be considered for weight-loss surgery:
- Have a BMI of 40 or more, or a BMI of 35 to 40 and an obesity-related ailment, such as heart disease, diabetes, high blood pressure, or severe sleep apnea.
- Weigh fewer than 450 pounds, which is the maximum weight allowed by hospital imaging equipment. A nutritionist can assist you if you need to lose weight to meet this criteria.
- Check to see whether your health insurance will fund bariatric surgery at UCSF if certain criteria are satisfied. Please be aware that we only accept Medi-Cal patients who are residents of San Francisco County.
How much weight do you have to lose before gastric sleeve?
The following pre-surgical diet may be required by your surgeon two weeks prior to surgery.
- Certain over-the-counter and prescription drugs should be avoided. Aspirin, ibuprofen (Advil/Motrin), naproxen (Aleve), and acetaminophen (Tylenol/Excedrin) are some of the medications that may be prescribed.
- Reduce body fat: Patients’ safety is improved by reducing fat in the belly and liver.
- Maintain and protect muscle tissue: On a low-calorie diet, increasing protein prevents the body from utilising muscle tissue as an energy source. Instead, the body will burn fat.
- Prepare the body for surgery and recuperation by eating a balanced diet, increasing protein consumption, and taking vitamin and mineral supplements.
- Prepare the patient for the post-surgery diet: The pre-surgery diet (low-calorie, high-protein, low-fat, low-carbohydrate) is very similar to the post-surgery diet (reduced-calorie, high-protein, low-fat, low-carbohydrate) and will help patients adjust to their new eating habits after weight-loss surgery.
Pre-surgery weight loss increases safety
Losing weight prior to surgery reduces the chance of problems and makes weight-loss surgery more secure.
The main goal of decreasing weight before undergoing weight-loss surgery is to reduce body fat in the abdominal area, particularly around the liver. If a patient’s liver is too enormous, a bariatric surgeon may have to postpone surgery. Shortening the operating time for laparoscopic surgery by reducing the size of the liver makes the process safer.
Losing enough weight before surgery allows for a less invasive surgical method (laparoscopic) rather than open surgery for super-obese patients (body mass index more than 50).
Amount of pre-surgery weight loss
Your bariatric surgeon will calculate the amount of weight loss required prior to surgery based on your health, weight, and bariatric procedure. Before undergoing weight-loss surgery, some individuals must reduce 10% of their body weight. Other people find that dropping 15 to 20 pounds before to surgery is sufficient to lessen the chance of problems.
It’s critical to adhere to your surgeon’s pre-surgery dietary and nutritional recommendations. A pre-surgical diet can help your body prepare for surgery and improve the results. It also aids with the adjustment to the dietary and eating adjustments required following weight-loss surgeryand for the rest of your life.
Why should someone consider having bariatric surgery?
Obesity is dangerous to one’s health. A person who is 40% overweight is twice as likely to die prematurely as someone who is ordinary weight. (After 10 to 30 years of being obese, this effect appears.) Obesity is responsible for over 300,000 fatalities each year in the United States alone. Obesity is linked to a number of serious and life-threatening illnesses, including:
Weight loss reduces the chance of death from these illnesses, according to studies. Patients usually no longer need to take drugs for these illnesses after six months of weight loss surgery. Furthermore, women who were infertile prior to surgery find that conception is achievable following surgery.
Who is eligible for bariatric surgery?
You must be morbidly obese and between the ages of 16 and 70 to be considered for bariatric surgery (with few exclusions) (weighing at least 100 pounds over your ideal body weight and having a BMI of 40). If you have certain pre-existing co-morbidities, such as diabetes, cardiovascular disease, hypertension, or sleep apnea, a BMI of 35 to 39 may also qualify you for the surgery.
If you’re a woman of childbearing age who wants to have a family, you should know that you can’t get pregnant for at least 18 months after surgery. Pregnancy is extremely harmful for you and your growing fetus because of the rapid weight reduction and nutritional inadequacies linked with bariatric surgery.
What bariatric surgical procedures are performed by surgeons at Cleveland Clinic?
The Roux-en-Y gastric bypass is the most routinely done malabsorptive operation. This procedure shrinks the stomach and changes digestion. It is possible to eat less food and absorb fewer calories. By separating the top end of the stomach, the bariatric surgeon produces a tiny pouch. The pouch is then linked to a Y-shaped piece of the small intestine, allowing food to bypass the lower stomach, duodenum (first segment of the small intestine), and first portion of the jejunum (the second segment of the small intestine). The operation establishes a direct connection between the stomach and the lower region of the small intestine, allowing calories and nutrients to skip portions of the digestive tract that absorb them.
The sleeve gastrectomy can also be performed laparoscopically. This treatment entails making five or six small incisions in the belly and performing the surgery with the help of a video camera (laparoscope) and lengthy instruments that are inserted via these incisions. Approximately 75% of the stomach is removed during a laparoscopic sleeve gastrectomy (LSG), leaving a narrow gastric “tube” or “sleeve.” During a sleeve gastrectomy, no intestines are removed or bypassed. It takes one to two hours to complete the LSG. Also accessible is an animated video of a sleeve gastrectomy process.
How much weight loss can be expected?
The majority of patients lose between 66 and 80 percent of their excess body weight after bariatric surgery, with the majority of this weight loss occurring 18 to 24 months after surgery.
Is it possible to gain the weight back after surgery?
Bariatric surgery has a proven track record of helping severely obese people reduce weight over time. However, with any form of weight loss, even surgery, there are no guarantees. Only if you are determined to making lifestyle and dietary adjustments for the rest of your life will you achieve success.
What are the risks for bariatric surgery?
All surgical treatments carry hazards, but grossly obese patients are especially vulnerable. Varying treatments carry different hazards, and your risks may be higher or lower than usual based on your own circumstances. It’s also worth noting that weight loss surgery techniques performed by bariatric surgeons with more experience have fewer difficulties. Surgery risks should be reviewed with your surgeon so that you may make an informed decision.
Can bariatric surgery be reversed?
The minimally invasive procedure of laparoscopic gastric banding is reversible. Gastric bypass surgery can be reversed in some cases. Reversal necessitates a second operation of equal or larger magnitude, with equal or greater hazards.
What if I need revision surgery?
Weight loss surgery is not a magic bullet, and while the majority of patients achieve their weight loss goals, revision weight loss surgery may be necessary in some cases. Whether the reason for pursuing revision weight loss surgery is due to insufficient weight loss/regain, unresolved co-morbidities, or medical difficulties, there may be a revision option.
Regardless of the previous surgery, revisional bariatric operations are usually difficult for a surgeon. To obtain the intended results, they require sufficient expertise. Bariatric Centers of Excellence, as designated by the American Society for Bariatric Surgical, offer a multidisciplinary staff and facilities for patients who require surgery revision. Patients who want gastric bypass revision or any other type of revisional surgery should seek out a surgeon at a bariatric facility who has extensive experience with revisional bariatric surgery.
What do I need to know about pregnancy after gastric bypass surgery?
Your body goes through a lot of changes in the first 18 months after gastric bypass surgery. Weight loss is a big one, but your body is also going through hormonal changes that make you more fertile. Please exercise caution during this period and ensure that you do not become pregnant by using a method of birth control. A pregnancy test will be performed if necessary before your procedure.
Much recent research demonstrates that pregnancies in people with a lower BMI are often safer than pregnancies with obesity-related problems. If you’ve had weight loss surgery and are thinking about getting pregnant, talk to your doctor about safe family planning. It’s also a good idea to tell your doctors about it at your weight reduction surgery consultation so they can offer advice and resources.
Because your body is undergoing significant changes during the first 18 months after gastric bypass surgery, it is not recommended to become pregnant until your weight and body have stabilized. Rapid weight loss after surgery causes hormonal changes and may deprive a developing infant of essential nutrients.
What can disqualify you from bariatric surgery?
There are some persons who are not candidates for obesity surgery for a variety of reasons. Your health comes paramount when determining eligibility, and your surgeon will assess the risks of significant weight gain against the surgery. You will not be considered if the procedure is likely to jeopardize your health or if the long-term health hazards outweigh the advantages.
A list of ‘contra-indications’ to surgery exist, which may indicate that you are not a good candidate for surgery. If you have any of the following symptoms, it does not mean you are ineligible for surgery; rather, it means you are in a higher risk category than others.
- Heart disease or serious lung issues in the past. These can make you more vulnerable to complications during anesthesia.
There are four items on this list, however, that if they apply to you, indicate that you are not a candidate for obesity surgery. They are as follows:
- Have you been diagnosed with Crohn’s disease or ulcerative colitis? (these are inflammatory bowel diseases).
Have a pre-existing disease that produces stomach or esophageal bleeding (windpipe).