Gastric Bypass Information
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Determining the Full Cost of Gastric Bypass Surgery
The cost of gastric bypass surgery can vary widely, depending on the
type of surgery performed and whether or not your insurance will help
pay for it.
Other factors include the length of time you have to stay in the
hospital, and whether or not any complications develop that require
a second surgery.
When there are no complications, the most common form
of weight loss surgery, the laparoscopic Roux-en-Y gastric bypass surgery,
can cost from $25,000 to $35,000, or more. The less invasive LAP-BAND®
system may cost from $17,000 to $25,000. If your insurance covers these
procedures, your out-of-pocket costs will be significantly reduced,
and should be limited to your deductible and copays, plus the cost of
any incidental procedures that are not covered.
The costs of any surgery will go up with complications,
especially if a new operation is required or if you need to stay in
the hospital longer. More insurance companies are now paying for the
surgery, but they do usually have strict requirements for eligibility,
and pre-approval is almost always needed. If an insurance plan does
cover these procedures, they will usually limit their coverage to one
or a few specific types of surgery, most commonly the Roux-en-Y gastric
bypass procedure. These limitations are based on a review of available
safety studies.
Even though many large insurance companies are now offering coverage
for weight loss surgery, many employers do not purchase policies that
cover the cost of gastric bypass surgery or other weight loss treatment
because of the additional cost.
Since your insurance company may require extensive pre-surgical counseling
prior to giving you approval for surgery, you should find out in advance
if the pre-treatment program they require is covered under your policy.
They may pay only for the surgery itself, and you may be responsible
for everything else. It’s always wise to find out in advance.
The obesity center will be able to tell you what the pretreatment program
will cost, and they’ll be happy to contact the insurance company
on your behalf to find out if their claims will be allowed.
What if there are complications?
If you insurance doesn't cover the procedure, they will probably not
cover any treatment that is needed if complications arise. This is often
overlooked by gastric bypass patients, who budget only for the surgery
in a best-case scenario and assume that if they need to go back to the
hospital, because of a gallbladder infection for instance, their insurance
will pick up the cost. Be sure to call your insurance company’s
customer service line before your surgery to find out what your contract
will cover.
Complications can include such things as leakage, infections and gall-stones.
Be sure to have a frank conversation with the counselor at the surgical
center so you will have a good understanding of all potential complications,
along with their risks and costs.
Other costs to consider are any long-term follow up sessions that may
be needed in order to prevent nutritional imbalances, and counseling
that may be required to make sure you don't regain any weight. Almost
all surgeons suggest ongoing nutritional counseling, and the cost for
this necessary assistance may not be covered by your insurance.
Finding out if gastric bypass is covered by your insurance:
Even if your obesity center calls your insurance company for you, you
should also call the health insurance company to make sure you understand
your coverage and your options. Also, in case of a future disagreement
with your insurance company, you should make a note of the day and time
of your call and the name of the representative who quotes your benefits.
If you make a decision based on this quote and claims are later denied,
you may be able to appeal. This may not be allowed if you get your information
only through your surgeon’s office.
To see if your policy covers weight loss surgery, find the chapter
in your benefit booklet that lists contract exclusions. An “exclusion”
is a service or diagnosis that the insurance contract will not pay for,
regardless of medical necessity.
Some plans exclude any claim with a diagnosis of obesity. This would
include all weight loss surgery and counseling, so you’ll have
to look elsewhere for financial assistance.
Other plans exclude “weight loss treatment,” but this may
only apply to diet pills and self-help programs. If you find this language
in your benefit booklet, you’ll need to find out how they define
weight loss treatment. Ask your surgeon’s office for the billing
code they will use for the surgery you are considering, and then call
the insurance company and ask if that code is covered. One common billing
code (CPT Code) used for Roux-en-Y gastric bypass is 43846.
If the billing code is not covered, ask them if it’s because
all weight loss surgery is excluded, or just the procedure you asked
about. You may be able to find another type of surgery that they will
allow, with certain restrictions.
If your insurance policy does cover gastric bypass surgery, with specific
restrictions or special requirements, find out if these requirements
are in writing. In newer policies the specific requirements will be
printed in your benefit booklet or on your company's intranet site.
One common restriction is the requirement that you have all your pretreatment
counseling and your surgery at a Center of Excellence. If this is the
case, find out which obesity center in your state has earned this designation.
Any surgery performed elsewhere will probably not be covered.
If your insurance will not cover any weight loss surgery, ask the obesity
center’s finance office if they make financial arrangements. They
are often able to help you find a way to pay for their services.
To read first-person accounts from people who have experienced
gastric bypass surgery, click
here.
Note: The information given here should
not be taken as medical advice. Be sure to talk to your doctor
about any concerns you may have about gastric bypass surgery.
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