Gastric Bypass Cost Comparison With or Without Health Insurance Coverage

Roca Labs® Natural Formula is probably the world’s strongest weight loss method. Each day that you take it, it expands in your stomach and leaves only a limited stomach space available for food intake for 10-16 hours. You easily eat half as much as before without feeling hungry, and begin to lose weight from day one. The price is $640, and you can also receive a 25% health insurance discount.

Gastric bypass surgery is a risky, invasive, virtually irreversible procedure and the cost is immense. On average, gastric bypass costs can run between $20,000 and $25,000. The surgery is sometimes covered by insurance, but this will depend on your company, policy, location and medical history. Even if you are covered, out-of-pocket co-payments for office visits and the surgery itself can run into thousands of dollars. Co-payments for weight loss surgery tend to be higher than for other operations, and can sometimes be as much as $5,000.

Hidden Costs of Gastric Bypass Surgery

The surgery itself is not the only cost; there are many hidden costs that prospective patients should be aware of:

  • Anesthesia fees
  • Hospital facility fee
  • Surgeon’s fee
  • Pre-op lab and X-ray fees
  • Nutrition counseling
  • Psychological counseling
  • Vitamins and supplements
  • Medical tests before and after surgery
  • Post-surgery painkillers and other medications
  • Some insurers insist that you join a care-management program, which could cost $1,500 or more

The following chart compares the Formula with gastric bypass, and several other types of surgeries:

Roca Labs® Natural Formula cost: $640
Gastric Bypass cost: $5,000 – $18,000
Roux-en-Y Gastric Bypass cost: $8,000 – $15,000
Lap Band / Gastric Banding cost: $4,000 – $15,000
Gastric Sleeve cost: $7,000 – $17,000
Duodenal Switch cost: $14,000 – $30,000

Roca Labs® Costs at Little as $480 with Your USA/Canada Health Insurance

Roca Labs® Formula can give you a similar result to gastric bypass surgery, but at a fraction of the cost. And unlike surgery, it has very few potential side effects, and it also includes the patented ingredient β-Glucan®, which balances blood sugar levels and fights your cravings for sweets and snacks – something that surgery isn’t capable of. You can also customize your dosage of the Formula, so you get as much or as little gastric bypass effect as you want. If you’re serious about weight loss, you want the best option out there. With Roca Labs® Formula, you’ll save 90% of the cost of a gastric bypass, and get a safe, flexible and effective method for losing weight.

Health Insurance Coverage

Aetna:  Per Clinical Policy Bulletin 0157, all patients require 2 years of documented medical history of morbid obesity, 3 months physician supervised non-surgical diet, exercise and behavior modification treatment and a psych evaluation if medically indicated.  StomaphyX is experimental and not covered.
Anthem Blue Cross: Per Clinical Policy Bulletin SURG.00024 insurance requires Attachment A to be filled out which requires psych and one diet consult.  Sleeve and StomaphyX are investigational and not covered.
Blue Cross Federal:  Pt must have BMI over 40 or BMI 35-40 with treated, uncontrolled co-morbid condition.  Sleeve is covered. StomaphyX is covered.
Blue Cross National CareFirst:  Per Policy Bulletin 7.01.036 insurance requires psych clearance and 6 month diet (or two 3 month diets).   Gastric sleeve is covered.  StomaphyX is experimental and not covered.
Blue Cross of Alabama:  Per Policy Bulletin 053 insurance requires 6 months diet (supervised by non-bariatric surgeon), three years medically-documented morbid obesity and H & P by bariatric surgeon.  They will accept Weight Watchers, LA Weight Loss, Jenny Craig, etc. with physician supervision and documentation.  Sleeve and StomaphyX are investigational and not covered.
Blue Cross of Arkansas:  Per Policy Bulletin 1998118 insurance requires BMI over 36 and failed structured weight loss program.  Gastric sleeve is covered if BMI >60 with cardiac or pulmonary co-morbidities.  StomaphyX is experimental and not covered.
Blue Cross of California:  (mandated coverage) Per Policy Bulletin SURG.00024 insurance requires one diet consult with history of previous weight loss attempts, psych evaluation, compliance letter from patient and treatment plan.  Gastric sleeve and StomaphyX are investigational and not covered.
Blue Cross Blue Shield of Delaware:  Insurance requires LOMN, cardiac, pulmonary and psych clearance and sleep apnea work-up.
Blue Cross Blue Shield of Florida:  Per Policy Bulletin 02-40000-10 insurance requires five-year history, 6 month diet, psych evaluation and TSH showing no endocrine disorders.  Sleeve and StomaphyX are investigational and not covered.
Blue Cross Blue Shield of Georgia: Per Policy Bulletin SURG.00024 insurance requires one diet consult with history of previous weight loss attempts, psych evaluation, compliance letter from patient, treatment plan, and attachment A.  Gastric Sleeve and StomaphyX are investigational and not covered.
Blue Cross Blue Shield of Illinois: Per Policy Bulletin SUR716.003 insurance requires five-year history, 6 month diet, psych evaluation and willingness to comply letter.  Sleeve and StomaphyX are investigational and not covered.
Blue Cross of Blue Shield Massachusetts: (mandated coverage) Per Policy Bulletin 379 insurance requires one diet consult with history of previous weight loss attempts.  Sleeve and StomaphyX are investigational and not covered.
Blue Cross Blue Shield of Michigan: Per Policy Bulletin – The Record of March 2005, insurance requires medically supervised 12 month diet failure, PCP clearance and psych evaluation.  Sleeve and StomaphyX are investigational and not covered.
Blue Cross Blue Shield of Minnesota: Per Policy Bulletin IV-19 insurance requires two year history of morbid obesity, 6 month diet failure, psych evaluation and compliance letter – Gastric Sleeve may be considered with BMI >50 and severe co-morbid conditions.  StomaphyX is experimental and not covered.
Blue Cross Blue Shield of Mississippi: Per Employee Access Policy Bulletin insurance requires five-year history of morbid obesity, documentation of failed diet attempts and TSH.  Sleeve and StomaphyX are investigational and not covered.
Blue Cross Blue Shield of Nebraska:  Per Policy Bulletin 1.23, insurance requires five-year history, no treatable medical cause for obesity and over age 16.  Sleeve and StomaphyX are investigational and not covered.
Blue Cross Blue Shield of New Mexico:  Per Policy Bulletin SUR716.003 insurance requires five-year history, 6 month diet, psych evaluation and willingness to comply letter.  Sleeve and StomaphyX are investigational and not covered.
Blue Cross Blue Shield of North Carolina:  Per medical policy bulletin SUR6710 insurance requires five-year history, psych evaluation, PCP clearance with TSH and diet consult.  Sleeve and StomaphyX are investigational and not covered.
Blue Cross Blue Shield of North Dakota:  Per Corporate Medical Policy insurance requires physician documentation of weight loss measures over the past 5 years, three-year weight history and psych evaluation.  Limited to one procedure per lifetime.  Sleeve and StomaphyX are investigational and not covered.
Blue Cross Blue Shield of Oklahoma:  Per Policy Bulletin SUR716.003 insurance requires five-year history, 6 month diet, psych evaluation and willingness to comply letter.  Sleeve and StomaphyX are investigational and not covered.
Blue Cross Blue Shield of Tennessee:  Per medical policy insurance requires completion of the Pre-Bariatric Evaluation Tool, requests documentation of specific dates of diets, length of diets with successes and failures for past two years, PCP must document 10% wt loss, five year history and psych evaluation.  Gastric sleeve may be covered on case by case determination.  StomaphyX is investigational and not covered.
Blue Cross Blue Shield of Texas:  Per Policy Bulletin SUR716.003 insurance requires five-year history, 6 month diet, psych evaluation and willingness to comply letter.  Sleeve and StomaphyX are investigational and not covered.
Blue Shield of California:  (mandated coverage) Per Policy Bulletin insurance requires completion of Prior Auth Review sheet, medical/surgical evaluation and clearance, psych evaluation and one diet consult.
Champ VA:  Per Policy Bulletin 38 CFR 17.270(a) and 17.272(a)(22) with Related Authority 32 CFR 199.4(e)(15) insurance requires BMI over 40, BMI over 35 with an associated co-morbid or revision due to complications.  Sleeve and StomaphyX are investigational and not covered.
Cigna:  Per Policy Bulletin 0051 insurance requires 6 month diet supervised by Primary Care Physician or physician other than a bariatric surgeon, medical evaluation by PCP, psych evaluation and two year history.  Sleeve and StomaphyX are investigational and not covered.
Empire Blue Cross:  Per Policy Bulletin SURG.00024 insurance requires diet consult, exercise consult, TSH, psych evaluation and attendance at support groups.  Sleeve and StomaphyX are investigational and not covered.
Excellus Blue Cross:  Per Policy Bulletin 7.01.29 insurance requires 5-year history, 6 month diet, TSH, documented 6 month abstinence from drugs/alcohol and psych evaluation.  Sleeve and StomaphyX are investigational and not covered.
First Health:  Per faxed policy insurance requires 3 month multi-disciplinary diet approach, psych evaluation, cardiac evaluation, pulmonary evaluation and post-op program.
Great West:  Effective April 1, 2008 Great West is Cigna – see Cigna for requirements.
Health Scope Benefits:  Per faxed policy insurance requires initial history and physical exam with office notes and any lab work done.
Highmark Blue Cross:  Per Policy Bulletin G-24 insurance requires physician supervised 6 month diet and exercise program and psych evaluation.  Sleeve and StomaphyX are investigational and not covered.
Horizon Blue Cross Blue Shield of New Jersey:  Per Policy Bulletin 022 insurance requires five-year history of morbid obesity, 6 month diet and exercise program and psych evaluation.  Sleeve and StomaphyX are investigational and not covered.
Humana:  Per Policy Bulletin insurance requires 6 month medically supervised diet, Primary Care Physician clearance and psych evaluation.  Sleeve and StomaphyX are investigational and not covered.
Independence Blue Cross:  Per Policy Bulletin 11.03.02e insurance requires medical clearance, psych clearance and one time in-depth diet consult.  Sleeve and StomaphyX are investigational and not covered.
Medicare:  Per Policy Bulletin S-131A insurance requires BMI of > 35 with at least one co-morbid condition, minimum two year history of morbid obesity, 6 month PCP diet or 3 month multi-disciplinary diet, exercise and behavior modification program with neither supervised by the surgeon and psych evaluation.  Sleeve and StomaphyX are investigational and not covered.
Pacificare – Secure Horizons:  Per Utilization Management at Pacificare, this is a general exclusion on the policy but should be submitted with LOMN, PCP, pulmonary, cardiac and psychiatric clearance along with three year history of diets tried and outcomes.
Premera Blue Cross:  Per Policy Bulletin CP.MP.PR.7.01.516*, only requires form 14784 faxed in with letter of medical necessity and after care explanation letter.  Sleeve and StomaphyX are investigational and not covered.
Principal Financial Group:  Per fax transmission insurance requires three-year history, 6 month diet supervised by physician other than surgeon and psych evaluation.
Regence Blue Shield:  Per Policy Bulletin 58 insurance requires 6 month diet, psych and documentation of willingness to comply.  Sleeve and StomaphyX are investigational and not covered.
Unicare:  Per Policy Bulletin SURG.00024 insurance requires completion of Attachment, one in depth diet consult, psych evaluation and compliance letter.  Sleeve and StomaphyX are investigational and not covered.
United Health Care: No set policy bulletin.  Each case to be evaluated individually.
United Health Care – THR:  Pt has a $4000 bariatric co-pay and must attend five months of Healthy Weight – NO LAP BAND.
Wellmark Blue Cross Blue Shield:  Per Policy Bulletin 07.01.17 insurance requires two year attempt with PCP supervised diet, three-year history and psych evaluation.  Sleeve and StomaphyX are investigational and not covered.

Gastric bypass surgery can cost anywhere from $18,000 to $22,000. The good news is that many insurance companies — both public and private — now offer coverage for this procedure.

Gastric Bypass Insurance Coverage: Overview

Insurance coverage for gastric bypass surgery varies by state, employer and insurance provider. Some insurers foot the entire bill, while others will pay 80 percent of the charges that are considered “customary and usual” for gastric bypass.

“Usual” refers to the normal rate charged for gastric bypass, and “customary” refers to the rates charged by providers in your area. These rates are arbitrary and determined by the insurer or provider. Some insurance companies or employers may also require a co-payment for gastric bypass surgery. It is also important to determine if gastric bypass complications are covered as well.

Most insurers who cover gastric bypass surgery will pay for all or some of the costs associated with anesthesia, the hospital facility and the surgeon’s fee. They may also pay for certain post-surgery costs, including diet and fitness plans, support groups and nutritional supplements. Insurers generally do not cover the cost of facial plastic surgery or body contouring surgeries after massive weight loss, such as face liftbreast liftpanniculectomy or liposuction. It is always best to check with your insurer regarding coverage before planning any surgery.

Does Medicare Cover Gastric Bypass?

Medicare, the U.S. government health plan for people 65 or older, will cover gastric bypass surgery for individuals with a body mass index (BMI) of 35 and at least one obesity-related health problem such as Type 2 diabetes, heart disease or sleep apnea. In addition, gastric bypass candidates must have completed a 6-month medically supervised weight loss program through their bariatric surgeon or their primary care physician.

For Medicare to cover the cost of the surgery, it must take place at a Center of Excellence, as designated by the American Society for Metabolic and Bariatric Surgery, or at a certified Level 1 Bariatric Surgery Center, as designated by the American College of Surgeons.

Both designations indicate that the centers and the surgeons practicing there have performed a specified number of bariatric surgeries. These centers must also have a bariatric team including surgeons, nurses, medical consultants, nutritionists, psychologists and exercise physiologists on hand. Such standards and safeguards are designed to protect the health of bariatric surgery patients.

These programs are regularly visited by experts to make sure they are still adhering to these standards, in which case they receive re-certification. Every program must report all of their outcomes, including complications, to a national database. This information will help surgeons better understand the risks and benefits of bariatric surgery, and can be evaluated by insurers who are considering covering bariatric surgery.

There is no pre-certification or pre-authorization needed for Medicare coverage of gastric bypass, but Medicare does not decide on eligibility until after you have had the surgery. Avoid this troubling scenario by contacting your local Medicare provider to know what is expected from you before you schedule your gastric bypass surgery.

Medicaid and Gastric Bypass Surgery

Medicaid is the federal government’s health care plan for low-income individuals and families. Medicaid’s coverage of gastric bypass surgery is decided on a state-by-state basis. Contact your state’s Medicaid office to see what policies are in place regarding coverage for gastric bypass surgery.

Private Insurance and Gastric Bypass Coverage

Different companies have different requirements for gastric bypass coverage. In general, the surgery is a covered benefit for individuals with a BMI of 40 or higher, or a BMI of 35 and higher with the presence of obesity-related illnesses.

If you work for a company with more than 1,000 employees, your employer can make benefit decisions. Gastric bypass surgery is usually not covered for individuals who work for small companies with less than 100 employees. To find out your company’s terms, check with your insurance company or human resources department.

Most private insurance companies have some requirements for bariatric surgery benefits. The approval process is more complicated than it is for other surgery procedures. Insurers will require a letter of medical necessity from your primary care physician as well as documentation of your obesity-related medical problems. In addition, the bariatric program will submit a request for authorization to your insurance company. Your gastric bypass surgery will not be scheduled until you receive this authorization.

Recent healthcare reform states that insurers can no longer put a limit on lifetime spending. In the past, insurers could place a “cap” on benefits, which would render a person virtually uninsured. There is no substitute for going over your covered benefits carefully to avoid any surprises. Most bariatric programs will review all of these issues with you in advance of your consultation appointment.

If your insurer turns you down, an appeal is always an option. Familiarize yourself with your plan’s appeals policy in advance.

You may choose to pay out of pocket for gastric bypass surgery. Some centers have “reinsurance” plans that you can buy into for coverage of any complications that may occur during the first year after gastric bypass surgery. You can also talk to the bariatric program about financing options, but these options do not include coverage for complications and may not be advisable.

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