Insurance
Most insurance plans cover bariatric surgery if the patient's weight and health meet standard criteria. Contact your provider to learn more by calling the number on your card and asking if obesity surgery (bariatric surgery) is covered.
Provide the procedure code (CPT):
- Roux-en-Y Gastric Bypass 43644
- Sleeve Gastrectomy 43775
- Duodenal Switch 43845
- Gastric Banding 43770
Ask: “Is there an exclusion in my group policy?” The answer should be “YES” or “NO,” not "Maybe."
If you have questions about whether or not your insurance plan will cover bariatric surgery, call our office at (631) 444-BARI (2274).
Helpful Terms
Understanding these terms may help you in discussing bariatric surgery with your health insurance provider and understanding your options:
Bariatric
A term referring to weight or weight reduction.
Body Mass Index (BMI)
A method of figuring out the degree of excess weight, based on weight and height.
Certificate of Coverage
A document provided by a health insurance company that describes the details of the plan’s policy, including requirements for eligibility, benefits, deductibles, maximums and exclusions of coverage.
Comorbid Condition
This is a disease or disorder related to a primary condition.
Fully Insured Plan
A type of health insurance plan in which the employer pays a monthly premium for a standardized health plan from an insurance company that assumes all risk and cost involved. The insurance company generally makes coverage decisions and must abide by state and federal regulations.
Morbid Obesity
A Body Mass Index of 40 or greater, which is roughly equal to 100 pounds or more over ideal body weight, or a Body Mass Index of greater than 35 with two or more comorbid conditions.
Self-Funded Plan
A type of health insurance plan in which the employer assumes all risks and costs in providing healthcare to employees and, therefore, decides what is and what is not covered, such as bariatric surgery. Self-funded plans are usually administered by an insurance company. This insurance company is often referred to as the third-party administrator (TPA) of the plan. The TPA performs administrative functions only and does not determine coverage. Self-funded plans are exempt from state regulations, including mandated benefits, premium taxes, and consumer protection laws, but they must meet federal regulations.
Summary Plan Description
Employers with self-funded health insurance plans are legally required to provide this document to their beneficiaries. The document provides plan participants with important information about their health benefits. This includes plan rules, financial information, and information on the operation and management of the plan. The information contained in the Summary Plan Description is similar to what is found in the Certificate of Coverage provided by a health insurance company.
