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Is Weight Loss Surgery Covered by Insurance?

Your Questions Answered

August 06, 2015

If you’re considering weight loss surgery, determining whether your insurance plan will cover your procedure is an important first step. With the exception of Medicaid, many insurance plans will cover weight loss surgery. However, individual policies may differ in their requirements and coverage. Use this guide to find out if your insurance will cover your procedure, and what to do if it does not.

Ask Your Insurance Provider if Morbid Obesity or Obesity is Covered by Your Individual Policy

You can find your insurance provider’s phone number on the back of your insurance card.

Give your provider the ICD9 code 278.01 (morbid obesity, BMI over 40) or code 278.00 (obesity, BMI unspecified).

If morbid obesity or obesity is a covered benefit, check that the procedure you are considering is also covered by giving your insurance provider the following codes:

Ask if Duke Regional Hospital, Duke Raleigh Hospital, Regional Anesthesia, Duke Department of Psychiatry, and the physicians of the Private Diagnostic Clinic at Duke University Hospital are accepted by your insurance.

You should also ask:

  • What percent of the total bill will I be responsible for?
  • Will I need to pay a deductible?
  • Are there specific criteria I need to meet to be considered for weight loss surgery?

Common Requirements for Weight Loss Surgery Insurance Coverage

Insurance providers may have different requirements for their coverage of weight loss surgery. Criteria can be mandated by your employer, a medical policy, or be plan specific.

Common requirements are:

  • A diagnosis of morbid obesity.
    • The NIH classifies morbid obesity as:
      • Over age 18
      • BMI over 40 or BMI over 35 with high blood pressure, type 2 diabetes, or other risk factors
  • Documented weight loss efforts over a period of time
  • Weight loss program mandated by the insurance company
  • Psychological testing
  • Smoking cessation prior to surgery
  • No evidence of substance abuse

If you have difficulty understanding your insurance company’s weight loss surgery coverage, our financial care counselors can provide an in-depth review of your policy. Contact them at 919-470-7003 or 919-470-7004.

Know Your Options if Your Insurance Doesn’t Cover Weight Loss Surgery

You have several options to consider. You can:

  • Switch to another insurance carrier during open enrollment. Before doing so, review which options will give you the best coverage of weight loss surgery.
  • Pay cash for your weight loss surgery without insurance. Our financial care counselors can give you estimates of what procedures will cost. Please note that payment is required in full before the procedure can be performed.
  • Participate in a medically supervised medical programs designed to lose and maintain weight loss. Learn about the program offered by the Duke Diet and Fitness Center.

If You Choose to Pay Cash

Contact our financial care counselors  at 919-470-7003 or 919-470-7004 to discuss your options and expenses. Payment plans are available.

Incentive Program for Duke Employees

If you’re a Duke employee, visit the Duke Human Resources website to learn if you are eligible for Duke’s pilot incentive program.

Disclaimer

The information provided is only general insurance and cost information and is not a guarantee of coverage. Benefits are always subject to the terms and limitations of individual insurance plans. Duke Health employees have no authority to make changes to individual plans. The availability of benefits is always conditioned on the patient’s coverage and the existence of a contract for planned benefits. Any questions regarding specific plan benefits and payments should be directed to your insurance company.  

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Weight Loss Surgery