If you’re considering weight loss surgery, determining whether your insurance plan will cover your procedure is an important first step. 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.
Is Morbid Obesity or Obesity Covered by Your Individual Policy
Contact your insurance provider to determine if obesity is covered. You can find your insurance provider’s phone number on the back of your insurance card.
Give your provider the ICD10 code E66.01 (morbid obesity, BMI over 40) or code E66.0 (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:
Common requirements are:
- Over age 18 (Some plans allow for surgery under 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
- Diagnosis of morbid obesity for a specific period of time prior to surgery
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 once your health history has been completed and submitted. This typically takes place at your first weight loss appointment. If you need to reach them following this appointment, please contact them at 919-470-7003 or 919-470-7005.
If Your Insurance Doesn’t Cover Weight Loss Surgery
These are your options:
- 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 weight loss program. Programs are offered at our locations, as well as the Duke Diet and Fitness Center.
If You Are Paying Cash
Contact our financial care counselors at 919-470-7003 or 919-470-7005.
Incentive Program for Duke Employees
If you’re a Duke employee, visit the Duke Human Resources to learn about eligibility requirements.
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.