Bariatric surgery in Maryland is often covered by insurance provided you meet certain eligibility criteria. Insurance companies are frequently changing their coverage criteria and have multiple medical plans, so please call you insurer’s member services number and confirm current requirements and eligibility for bariatric surgery coverage relevant to your case.
It’s important that you fully understand what “is” and “is not” covered by your insurance provider, however, do not attempt to get authorization for surgery yourself or ask you Primary Care Physician to do so. This must be done by our office staff in order to meet all coverage criteria. Here are some helpful hints to assist with the authorization process:
- Read and understand your insurance provider’s policy of coverage.
- Get a referral and copy of medical records from your primary care physician if required.
- Keep accurate, detailed records of visits to health care providers for non-surgical weight loss programs when required by your plan.
The insurance company will typically ask for the following information and documentation (Please be prepared to assist us with providing these upon request):
- Current weight, height and BMI.
- Verification from a physician that you are 100 pounds or more over your ideal body weight.
- Surgery recommended along with any post-operative follow-up care, including nutritional and psychological support.
- A detailed medical history including co-morbidities (i.e., the presence of one or more diseases in addition to obesity).
- Medical records including your evaluation, treatments performed to date, and specific types of lab work done.
- Three (3) to six (6) months of a documented dieting and exercise routine (must include dates and results).
- A psychological/psychiatric evaluation.
- Evaluation by surgical bariatric dietician.
If we have submitted an authorization for surgery requests and it was denied, we have the right to appeal the decision on your behalf. Being denied coverage for surgery happens to some patients and this initial set back does not mean that you’ve reached the end of the road. Some insurance providers may initially deny bariatric surgery claims automatically the first time they are submitted, and can be more receptive to follow-up appeal letters and peer-to-peer reviews with medical directors.
If you have questions about the insurance process, please don’t hesitate to contact our office.
Most frequently encountered requirements by insurance company:
- AETNA: Standard NIH weight criteria, 5 years documented by a doctor history of obesity, supervised 6-month (or two 3-month periods) diet within 2 past years, evaluation by dietitian & psychologist.
- Blue Cross/Blue Shield: Standard NIH weight criteria, supervised 6-month (or two 3-month periods) diet within 2 past years, evaluation by dietitian & psychologist.
- Blue Cross Federal: Standard NIH weight criteria, 3-6 months supervised diet, evaluation by dietitian & psychologist.
- CIGNA: Standard NIH weight criteria, supervised 6-month diet within 2 past years, evaluation by dietitian & psychologist.
- United/MAMSI/MDIPA/Optimum Choice: Standard NIH weight criteria, 5-year weight history, evaluation by dietitian & psychologist. Some plans may require 6 months supervised diet.
- United/MAMSI/MDIPA/Optimum Choice Federal: Standard NIH weight criteria, supervised 6-month (or two 3-month periods) diet within past 2 years, evaluation by dietitian and psychologist.
- Medicare/Medicaid: Standard NIH weight criteria, supervised 6-month diet, evaluation by dietitian and psychologist, participation in preparation/conditioning program with surgeon for 3 months. Eligible co-morbidities include hypertension untreatable with 2 or more medications, type II diabetes, obstructive sleep apnea, severe arthritis requiring joint replacement, or fatty liver. Weight loss of 10 percent or more before surgery makes patient ineligible for surgery, and revision procedures are not covered unless there is a complication of initial surgery.