Whether to have gastric banding surgery is a very important decision. There are so many factors to consider—health, personal goals, family, and as with every other decision in life, finances.

Although highly effective for controlling obesity and its related medical conditions, surgery is expensive. But, remember, paying for gastric banding surgery is a lifetime investment in your health and in your life. Imagine being able to play with your children or grandchildren the way you’ve always wanted, not worrying about whether you’ll be able to fit into a theater seat, or returning to physical activities that you have not been able to enjoy for years.

The cost of the procedure will be determined by the surgeon you select and the hospital where the procedure is performed. In general, the cost ranges from $16,000 to $25,000, depending on the hospital fees and surgeon fees. The hospital will purchase the device and it is usually billed to you as a part of the entire cost of the procedure.

Knowing whether insurance will pay for the surgery is a critical part of your decision-making process. For many people, bariatric surgery with the Realize™ Personalized Banding Solution is affordable because it is included in their health insurance coverage.

Without insurance coverage, bariatric surgery is a medical procedure you’ll need to pay for on your own. Because it is an investment in their health and quality of life, many people feel that, even without insurance, the surgery is well worth the cost.

Employers who offer coverage vary by state and insurance provider. If you’re thinking about gastric banding surgery in the near future, start looking at your insurance benefits today. Some insurance plans cover all or part of the cost.  By calling 1-866-REALIZE, we can help you check to see if your employer provides insurance coverage options. You can also use our guide “Advocating Bariatric Surgery Insurance Coverage at Your Workplace” as you begin the process of determining insurance coverage.

Since every insurance policy is unique, it's important that you thoroughly understand your certificate of coverage to know exactly what is and isn't covered through your plan.

To qualify for insurance coverage, many insurers require patients to have a history of medically supervised weight loss efforts. Insurance companies may consider the following efforts when evaluating the appropriateness of bariatric surgery including laparoscopic gastric banding:

Keeping track of every visit you make to a healthcare professional for obesity-related issues or visits to supervised weight loss programs.

Making note of other weight loss attempts made through diet centers and fitness club memberships.

If your bariatric surgeon recommends laparoscopic adjustable gastric banding, he or she will be required or can assist with preparing a letter to obtain preauthorization from your insurance company. The goal of this letter is to establish the medical necessity of bariatric surgery and gain approval for the procedure. The following information is generally included in the preauthorization letter:

Communicating with Your Insurance Company

1. Your height, weight, and Body Mass Index, and any documentation you might have as to how long you have been overweight.
2. Simply describing your condition as morbid obesity is not enough. A full description of all your obesity-related health conditions, including records of treatment, a history of medications taken, and documentation of how these conditions affect your everyday life, is necessary.
3. A detailed report of how your excess weight affects daily activities, such as walking, tying your shoes, or maintaining personal hygiene.
4. A detailed history of the results of your dieting efforts, including medically and non-medically supervised programs, medical records, and records you may have kept of payments to and meetings you’ve attended with commercial weight loss programs. Visit our Resource Library for a helpful tracking sheet template.
5. A history of exercise programs, including receipts for gym memberships.
6. Confirmation of your mental health. This should indicate that you are able to understand, tolerate and comply with all phase of care and that you are committed to long term follow up requirements. This includes documentation that you have completed a preoperative mental health assessment and that your treatment plan includes counseling to support any psychological issues.
7. Ask your doctor to include clinical information about the effectiveness of bariatric surgery, particularly the control or loss of obesity-related health conditions.

Normally, your insurance provider will respond to your request within 30 days. You should schedule a follow-up if you have not heard from your insurance company in that amount of time.

The health insurance coverage information contained in this section is provided for information purposes only and represents no statement, promise or guarantee by Ethicon Endo-Surgery, Inc. concerning levels of coverage, reimbursement, payments or charge.

If your insurance company denies your request, you can make an appeal. At this point, consider hiring an insurance lawyer or insurance advocate. The insurance lawyer or advocate should have an in-depth understanding of the appeals process, as well as any laws that apply, and how to go about responding to the insurance company. With some insurance carriers, the number of appeals that you can make is limited. So be sure to learn as much as possible about the appeals process ahead of time.

In addition to making an appeal, you can also file a written grievance against your health plan. A grievance is a complaint against any plan decision, policy or action related to the availability, delivery or quality of health care services. All health insurance plans have internal grievance and complaints procedures. If you have a complaint, follow the plan's procedures.

Another option is an external grievance. This process is independent of the insurance company’s internal grievance process. Contact your state health insurance commissioner to see what external grievance and complaint procedures may exist in your state.

Even when patients have exhausted their appeals processes, they still may have options. Options can include: 

Independent Review Board

Many states are required to have an independent, external board to evaluate the validity of denied coverage. This option is available to people in more than 40 states.

To look at your state’s website for filing instructions, click on that state. You may also locate a phone number to your state’s insurance commission in your phone book under government services. You can also ask your insurance company, employer benefits department or bariatric surgery program coordinator, if requesting an independent review of your case is an option. In states where an independent review is required, decisions usually are issued within 60 days.

Arbitration

As an alternative to a lawsuit, some health plans require or offer an option of seeking a coverage decision using a neutral third party. Arbitration occurs when an opinion or an evidence-based decision is made by an unbiased person. Instead of going to court, the parties dispute the case in front of an arbitrator that the parties have agreed on based on his or her experience and expertise in the field. This procedure is often less costly and less time-consuming than going through the court system. 

It is important to remember that arbitration might not always be an option or a better way of disputing a denied appeal. It is recommended to contact your plan to verify the options available to you.

Litigation

When a lawsuit is filed and brought before a court, it is called litigation.  This formal legal action is usually taken in the event all other options for obtaining coverage for your surgery have been exhausted. This option is expensive and time consuming, and often used as a last resort. You can consult with your bariatric surgery program coordinator to identify local legal counsel in the event you feel legal action is required to gain access to bariatric surgery.

State Insurance Departments and Phone Numbers

Click on state and phone number to go to the state’s insurance department webpage

If your insurance policy does not cover bariatric surgery, you may want to discuss alternative financing options with your bariatric program.

Next: REALIZE Financing Program >