Office Policies

Insurance Option

Many insurance companies recognize the serious health threats of obesity and do cover bariatric weight loss surgeries. If you have insurance and your health benefits cover the procedures, your out-of-pocket expenses and requirements will be determined by:

Deductible, co-payment or co-insurance
The terms of any contracts the Center for Digestive and Metabolic Surgery and Orlando Health may have with your insurer. Eligible patients should have a BMI of 40 or higher (morbidly obese) or a BMI of at least 35 with co-morbidities (obesity related health conditions) such as diabetes, sleep apnea, heart disease, high cholesterol or hypertension (high blood pressure). Eligible patients must also have attempted and failed at previous weight loss efforts.
Evaluation and Recommendation
Preparing for bariatric weight loss surgery involves evaluations and recommendations by several health care professionals along with your surgeon. They may include a primary care physician, a cardiologist, pulmonologist, nutritionist and a psychologist. This team works together to develop a comprehensive treatment plan.
Letter of Medical Necessity
A Letter of Medical Necessity is written by the patient's primary care physician detailing the patient's health condition and why weight loss surgery is necessary. It often lists the patient's weight, body mass index (BMI), how many years the patient has been overweight/obese, prior attempts to lose weight, participation in a medically supervised weight loss program, and obesity related health problems.
A Medically Supervised Weight Loss Program
Many insurance companies will not consider a request for weight loss surgery unless a patient has previously participated in a medically supervised weight loss program. This type of weight loss program includes diet, exercise or medication for weight loss which is monitored by a doctor. The purpose of this is to show a patient's efforts at weight loss and that the patient is willing to make the necessary dietary and behavioral changes for bariatric surgery.
Helpful Documents for Insurance Approval
In addition to the Letter of Medical Necessity, you will need to gather many documents to improve the probability of receiving surgery approval. Helpful documentation includes all diet records, medical records, medical tests, records for medically supervised diet attempts, receipts for exercise equipment, gym memberships, or diet programs such as Weight Watchers, Jenny Craig, or Curves, and any other documentation that shows your attempts at weight loss over the years.

Self-Pay Option

At the Center for Digestive and Metabolic Surgery, we are committed to helping people with obesity and metabolic/digestive disorders live a new and healthy life. It is our goal to find a way to help you.

If you don’t have insurance or your insurance does not cover bariatric weight loss surgery, we will work with you to make the surgery reasonable for you as a self-pay patient.

As a self-pay patient, you can generally expect your out-of-pocket costs to range between $12,000 and $23,000.

Eligible patients should have a BMI of 40 or higher (morbidly obese) or a BMI of at least 35 with co-morbidities (obesity related health conditions) such as diabetes, sleep apnea, heart disease, high cholesterol or hypertension (high blood pressure). Eligible patients must also have attempted and failed at previous weight loss efforts.
Preparing for bariatric weight loss surgery involves evaluations and recommendations by several health care professionals along with your surgeon. They may include a primary care physician, a cardiologist, pulmonologist, nutritionist and a psychologist. This team works together to develop a comprehensive treatment plan. When you schedule your consultation with one of our surgeons, one of our staff members will discuss our self-pay program with you.

How do I verify my insurance coverage?

Many insurance companies cover bariatric weight loss surgery; some do not. Others will allow surgery based on specific parameters, for example, if surgery is deemed medically necessary or if you meet the national guidelines for morbid obesity. To find out if your insurance covers bariatric procedures, refer to the package you received when your insurance coverage began or contact your Human Resources representative through your employer to learn if they selected this coverage benefit for your plan. You may also call the insurance company directly and speak to a representative.
Procedures, services and medications that are not covered are usually listed under "What Is Not Covered" or "When the Plan Does Not Pay Benefits." When you read this section or when you speak with a representative, pay close attention to statements that address exclusions for weight management, obesity treatment, weight-loss surgery or complications from bariatric or weight-loss surgical procedures.

Appeals Process

Appealing Insurance Denials for Bariatric (weight loss) Surgery

When a submission is requested for pre-authorization of weight loss surgery and a denial is received from your insurance company, it may be discouraging but it can be appealed. Many denials are based on factors which can be worked out, such as missing medical history and weight loss documentation. If you receive a denial, contact the insurance company and find out the reasons for the denial and what information they need to grant bariatric weight loss surgery. Many individuals have followed up with their insurance company to determine the reasons for the denial, then met those requirements and succeeded at having their denial overturned. The insurance company may not make the process easy on you, but if you continue to work on your own behalf you may eventually be granted insurance approval for bariatric (weight loss) surgery.

Appealing Insurance Denials Indicating Lack of Medical Necessity

Insurance requests for bariatric (weight loss) surgery are often denied because the insurance company deems a lack of medical necessity. To be considered medically necessary, the insurance company needs evidence to support this claim - such as documentation showing that other weight loss methods have already been tried and why bariatric (weight loss) surgery is necessary to treat a serious or life-threatening disease (obesity or type 2 diabetes). Bariatric (weight loss) surgery is considered a last resort treatment and will not be covered unless other methods of weight loss have been exhausted. Lack of proper documentation, such as medical records for one to five years of physician supervised dieting, psychiatric evaluation, or a letter from your physician stating your obesity co-morbidities, can result in a medical necessity denial. Make sure you provide the insurance company with the information required to support the claim that bariatric (weight loss) surgery is medically necessary for you.