Gastric Sleeve surgery, one the most effective weight loss tools, is often covered by most large insurance providers. However, getting approval can be quite difficult. Even if you meet the requirements, you may still be denied for various reasons. To be eligible for gastric sleeve insurance coverage, you will have to meet a variety of requirements and qualifications.

Gastric Sleeve Insurance Requirements

Every insurance provider approves coverage based on different prerequisites and criteria.  Contact your provider to determine if they include bariatric surgery such as gastric sleeve and gastric bypass. For gastric sleeve surgery, most health insurance companies require the following:

  • Class III obesity (Body Mass Index of 40 or above), or
  • Class II obesity (BMI of over 35) with at least one obesity-related comorbidity (health problem), such as type 2 diabetes
  • Must have documentation in your medical records confirming that previous attempts at medical treatment for obesity have been unsuccessful

Gastric Sleeve Insurance Coverage Minimum Requirements

Anthem Blue Cross Blue Shield Coverage

Blue Cross Blue Shield (BCBS) provides supplementary coverage for bariatric procedures, such as lap bands and gastric sleeve. However, the approval consists of:

  1. Medical necessity assessment
  2. Documentation of failed weight loss attempts
  3. Specialist evaluation
  4. Psychological evaluation
  5. Insurance preauthorization

The recommended surgery is one of the following procedures:

  • Biliopancreatic bypass with duodenal switch
  • Laparoscopic adjustable gastric banding
  • Roux-en-Y procedure up to 150 cm
  • Sleeve gastrectomy
  • Vertical banded gastroplasty

BCBS approval process (published 2023)

– Gastric bypass and gastric restrictive procedures are considered medically necessary when all of the following criteria are met:

  • An individual is aged 18 years or older
  • A body mass index (BMI) of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to:
    – Diabetes mellitus
    – Cardiovascular disease
    – Hypertension
    – Life-threatening cardio-pulmonary problems (for example, severe obstructive sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy)

– Documentation of all of the following is needed as well:

  • Past participation in a weight loss program
  • Inadequate weight loss despite a committed attempt at conservative medical therapy (for example, comprehensive lifestyle interventions, including a combination of diet, exercise, and behavioral modifications)
  • Pre-operative medical and mental health evaluations and clearances
  • Pre-operative education, which addresses the risks, benefits, realistic expectations, and the need for long-term follow-up and adherence to behavioral modifications
  • A treatment plan which addresses the pre- and post-operative needs of an individual undergoing bariatric surgery

BCBS Bariatric Coverage Process - MBC Call us 855 768 7247

Aetna Obesity Surgery Policy

Most Aetna HMO and QPOS plans exclude coverage of surgical operations, procedures, or treatment of obesity unless approved by Aetna. They pretty much have the same medical necessity and other requirements similar to BCBS. Check out Aetna’s website for more information about their clinical policy.

Humana Coverage for Bariatrics

Unless it is stated in the policy, Humana covers your obesity surgery. Humana has a Bariatric Management Team to help you through the operation and six months post-operation. Here is Humana’s medicare eligibility website.

United Healthcare Bariatric Surgery Medical Policy

UnitedHealthcare’s obesity surgery medical policy applies to all Commercial plans. It also applies to Individual Exchange plans in all states except for Alabama, Colorado, Florida, Georgia,
Kansas, Louisiana, Mississippi, Missouri, Ohio, Oklahoma, South Carolina, Tennessee, Texas, Virginia, Washington, and Wisconsin. Check out the UHC’s in-depth bariatric surgery medical policies.

Cigna’s Bariatric Coverage Policy

Most of Cigna’s policies cover weight loss surgery to help very overweight get trimmed.

  • 18 years or older (reached skeleton growth)
  • 40+ Body Mass Index (BMI) or 35+ BMI with at least one clinically significant obesity-related comorbidity,
    – Mechanical arthropathy in a weight-bearing joint
    – Obstructive sleep apnea
    – Hyperlipidemia
    – Pulmonary hypertension
    – Coronary artery disease
    – High cholesterol
    – Type 2 diabetes
    – Fatty liver disease
  • Failed Doctor Supervised Weight Loss Program

Check out the information authored by their HealthWise staff.

Steps to Get Approved for Gastric Sleeve Surgery

7 Steps to Get Approved for Gastric Sleeve Insurance

To prove to your insurance carrier that your surgery is medically necessary, you typically need to follow the following steps:

  1. Have the minimum requirements for insurance coverage
  2. Follow a supervised weight loss program usually provided or accepted by your insurance company
  3. Set up a consultation with a bariatric surgeon who accepts your insurance
  4. Receive clearance from your primary physician. A letter is required for insurance approval
  5. Psychological evaluation with a letter of approval
  6. Nutritional evaluation with a letter of approval
  7. Send all evaluation documentation to your insurance provider. Include a detailed health history with proof of any past obesity-related comorbidities and failed attempts at weight loss programs

If approved, start the scheduling process for your bariatric surgery. If you are denied, try seeing your eligibility for gastric sleeve surgery in Mexico.

How Long Does it Take for Insurance to Approve Gastric Sleeve?

Every insurance provider has different time periods to get back to you for approval. Generally, it takes between 2 weeks to 1 month to be approved. Sometimes, insurance providers will approve patients before finishing their required evaluations and documentation – even though it still needs to be done.

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Ask your insurance provider about the approval process and the estimated duration. Insurance guidelines typically require up to a year for approval.

Does Health Insurance Cover Weight Loss Surgery

What To Do if You Are Denied Insurance Coverage

If you can’t afford or get insurance for bariatric surgery in the US or Canada, consider medical tourism. Medical Tourism connects you to certified facilities and surgeons from across the world, including Mexico.

In Mexico, gastric sleeve surgery is usually self-pay but at a fraction of the price in the other countries. You can find locations like Mexico Bariatric Center® with packages starting at $4,395 that offer payment plans and financing options. The requirements for gastric sleeve surgery include;

If you want a complete guide to pay for bariatric surgery without insurance, check out our guide.

Additionally, there are great alternatives besides getting weight loss surgery in the United States. Mexico Bariatric Center has become an industry leader in weight loss surgery in Tijuana, Mexico. MBC specializes in Gastric Sleeve (vertical sleeve gastrectomy), gastric bypass surgery, gastric banding (LAP-BAND), and much more.

The cost of VSG starts at $4,395 and ranges depending on which certified surgeon you choose and your medical history. In order to see if you Pre-Qualify, click here.

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