Your policy must cover weight loss surgery in order to be eligible for coverage. Not all insurance policies provide coverage. Please contact Kaiser Permanente directly to find out if your policy covers you.
Weight loss surgery is covered by Kaiser Permanente. Kaiser Permanente covers gastric bypass, lap band, and gastric sleeve surgery if you satisfy the standards specified below.
How do you qualify for gastric sleeve with Kaiser?
Surgery is a tool for highly obese people who are unable to lose weight through other means. In most circumstances, Kaiser Permanente will support weight loss surgery if you meet the criteria listed below.
- Severe sleep apnea, high cholesterol, diabetes, and other comorbidities are examples.
- Within the last two years, you’ve completed a medically supervised weight loss program.
- For at least three of the last five years, I’ve been morbidly obese. A physician should document this (e.g., annual visits to your OB/GYN, etc.).
- A psychological examination was successfully performed. There are no concerns that will make sticking to your new diet and lifestyle post-surgery challenging.
Does Kaiser have a weight loss program?
If you need to lose at least 40 pounds and want to make positive, long-term changes that will: Improve your health, the Kaiser Permanente Medical Weight Management Program may be the right fit for you.
Does insurance pay for gastric bypass surgery?
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.
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).
Does Kaiser Cover skin removal after weight loss?
Oakland, California After a lengthy trial in a 10,000-member class action, a California state court judge concluded that Kaiser Permanente cannot systematically characterize the excision of excess skin following bariatric weight loss surgery as a cosmetic treatment, but that doctors might determine on a case-by-case basis.
What is the difference between gastric bypass and gastric sleeve?
Working with your doctor to determine the best weight loss technique for you is recommended.
- On average, gastric bypass patients lose 50 to 80 percent of their excess body weight in 12 to 18 months.
- Patients who have a gastric sleeve lose 60 to 70 percent of their excess body weight in 12 to 18 months on average.
- Gastric bypass surgery is usually suggested for individuals who are extremely obese, with a BMI of 45 or more.
Learn more about our surgical choices and compare the differences between the various bariatric surgery treatments available at UPMC Bariatric Services.
Will Kaiser pay for Weight Watchers?
Employees and family members may be eligible for a 50 percent to 100 percent reimbursement, depending on their eligibility. For further information, call Kaiser Permanente’s HR Service Center at 877-457-4772.
How does the Kaiser diet work?
This diet should be followed for three days at a time. You can drop up to 10 pounds in three days. After three days, you can resume normal eating habits, but don’t overdo it. After four days of ordinary eating, you can resume the three-day diet.
Why is weight loss surgery not covered by 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
Although you may meet conventional and widely-accepted standards for medical necessity, your insurer 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
It’s crucial to thoroughly evaluate denials because deadlines for appeals may be fast-approaching.
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 levels 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.