Before you consider weight loss surgery as an option in managing your obesity, it would be helpful to contact your insurance company to verify that:

• Weight loss surgery is covered by your policy
• Durham Regional Hospital, Duke Raleigh Hospital, and the physicians of the Private Diagnostic Clinic at Duke University Medical Center are part of your coverage
• What percentage of the total bill you will be responsible for and is there a deductible?

To qualify for insurance coverage you must have either:

• A body mass index of greater than or equal to 40
• Body mass index between 35 and 39 and at least one major medical co-morbidity, such as:
  • Respiratory problems (sleep apnea or hypoventilation syndrome)
  • Diabetes
  • Hypertension

Patients should also check to see if their insurance provider requires documentation of medical attempts to lose weight prior to surgery.

Some insurance carriers require six consecutive months of documented weight loss attempts within the last two years. Patients’ primary care physicians can help them complete necessary documentation, which may include:

• Vital signs (must include weight)
• Discussion of and suggestions for current dietary program
• Discussion of physical activity or exercise program and recommendations
• Discussion of behavioral modification, including successful changes made
• Discussion of or use of FDA approved pharmacotherapy, if appropriate

Please note that these are just guidelines. Specific requirements vary according to insurance plans.

Insurance companies that do not require documentation of physician supervised weight loss attempts:

• Blue Cross Blue Shield of North Carolina
• Federal Blue Cross Blue Shield requires three months of documentation of physician supervised weight loss program. This has to be done for a total of four months.
• Humana Gold

Insurance companies that require six months documentation of physician sponsored weight loss:

• CIGNA
• Aetna
• Medicare
• Medicare Access (Medicare Replacement Plan)
• Tricare
• Most out-of-state Blue Cross Blue Shield plans require three to six months of documentation

The following plans require six months documentation of physician sponsored weight loss and six months documentation of weight management:

• Duke Select
• Duke Blue Cross Blue Shield (Blue Care Plan)

Weight management programs can include Weight Watchers, Pathways to Change (Live for Life), or the Duke Diet and Fitness Center. A $4,000 copay is required before surgery.

What if my insurance will not cover weight loss surgery?

If your insurance carrier will not cover weight loss surgery there are options you can take if you still wish to proceed with surgery:

• Self-pay, or paying out of pocket, is an option for all surgical procedures. Contact the clinic to inquire about rates. There is also a new option for self-pay gastric banding patients to receive surgery at the James E. Davis Ambulatory Surgical Center.

If you cannot understand the information given by your insurance company on coverage of obesity care, please contact the financial care counselor at the Durham clinic (919) 470-7003 or the Raleigh clinic (919) 862-2744.