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.
Who qualifies for Orbera?
You must be an adult with a BMI of 30 to 40 and be willing to participate in a medically supervised program to be eligible for Orbera.
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.
Does Medicare cover Orbera balloon?
The use of a gastric balloon is not reimbursed by Medicare since the device’s long-term safety and efficacy in the treatment of obesity has yet to be proven.
What if my 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 documentation (medical chart notes, personal records, logs, or receipts) from previous 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 requirements 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.
Does insurance cover liposuction?
Liposuction and its complications are not covered by most health insurance plans, however many plastic surgeons offer patient financing arrangements, so be sure to inquire.
How much can you lose with Orbera?
It’s crucial to remember that the gastric balloon is a weight-loss tool that works best when used in conjunction with a comprehensive lifestyle program administered by your doctor and a skilled allied health team. The amount of weight loss that can be predicted varies by device, however most will accomplish 15-20% TBWL (Total Body Weight Loss; for example, a 100kg person should expect to lose 15-20 kg on average*). Finally, how much weight you lose and maintain will be determined by how closely you follow your doctor’s and allied health team’s advice.
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.
Can you have a gastric balloon twice?
A second surgery, on the other hand, increases the risk of problems such as infection, bleeding, and gastrointestinal leakage. Because of these concerns, if you acquire weight as a result of bad diet or exercise habits, gastric bypass surgery is rarely performed.
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!