Is Weight Loss Surgery Covered by Insurance?

Our team is here to help you get the answers you need so you can pursue weight loss surgery without it being a financial challenge. Our financial coordinators determine what your insurance plan states is medically necessary to obtain approval for surgery, as well as what if any, documentation it requires. For example, some insurance plans require no documentation of your past weight loss attempts, while others require that your primary care doctor provide 12 months of documentation.

We also help you understand what expenses you can expect that go beyond your insurance coverage. 

Here’s what you need to look for to find out if your insurance will cover your procedure, and what to do if it does not.

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:

• Roux-en-Y gastric bypass: CPT 43644
• One anastomosis gastric bypass: (mini gastric bypass) 43645
• Gastric sleeve: CPT 43775
• Duodenal switch: CPT 43645
• Single anastomosis duodenal ileostomy (SADI): 43659

Ask if Duke Regional Hospital, Duke Raleigh Hospital, and Duke University Health system providers 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?

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:

• 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

Some criteria may change soon, including having a BMI less than 30. While these criteria are not currently accepted by most insurance companies, we can work with you to help get coverage. 

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. Please call 919-470-7004 If you need to reach them following this appointment.

You have several options from which to choose if your insurance company does not cover or approve your surgery. You can:

• Switch to another insurance carrier during open enrollment. Before doing so, review which options will give you the best coverage for 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. Please our financial care counselors at 919-470-7004 for more information.
• Participate in a medically supervised weight loss program. Duke Health offers several options to help you lose weight under medical supervision.

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.