Does Health Insurance Cover Weight Loss Surgery Based on BMI?

Does Health Insurance Cover Weight Loss Surgery Based on BMI?

Obesity has been a pressing issue for many years. According to the Centers for Disease Control and Prevention (CDC), more than one-third of adults in the United States are obese. Obesity can lead to several health issues, including heart disease, stroke, high blood pressure, type 2 diabetes, and the list goes on. The health risks associated with obesity have prompted several people to seek weight loss surgery. However, not everyone can afford the hefty price tags associated with these surgeries. So, the question is – does health insurance cover weight loss surgery based on BMI?

BMI or Body Mass Index measures body fat based on a person’s height and weight. A person who has a BMI of 30 or higher is considered obese. Weight loss surgery is an important step towards reducing the risks associated with obesity. Some of the common weight loss surgeries include gastric bypass, laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. The cost of these surgeries can range from $20,000 to $50,000. However, not everyone has the luxury of paying for these procedures out of pocket. Thankfully, many health insurance plans provide coverage for weight loss surgery for people who meet certain criteria. If you’re unsure about your BMI, you can use a BMI calculator to assess it accurately.

Before we dive into the specifics of insurance coverage, let’s take a closer look at the various types of weight loss surgeries. Gastric bypass surgery is the most common weight loss surgery. It involves dividing the stomach into two parts – a smaller upper part and a larger lower part. The small intestine is then rerouted to connect to the smaller upper part of the stomach. Laparoscopic adjustable gastric banding (LAGB) involves placing a silicone band around the upper part of the stomach. Laparoscopic sleeve gastrectomy involves removing a portion of the stomach and creating a sleeve-shaped stomach. Biliopancreatic diversion with duodenal switch (BPD/DS) involves removing a portion of the stomach, rerouting the small intestine to connect to the remaining stomach, and altering the way the digestive system works.

Now, let’s get back to our original question – does health insurance cover weight loss surgery based on BMI? The answer is – it depends. Insurance companies have their own set of guidelines and criteria for covering weight loss surgery. However, most insurance companies require the following criteria to be met before they cover weight loss surgery:

BMI of 40 or higher or BMI of 35 or higher with at least one obesity-related health issue

History of documented failed attempts at weight loss

A psychological evaluation to determine the patient’s mental readiness for surgery

A written recommendation from a physician stating that weight loss surgery is necessary for the patient’s health.

Insurance companies may also require patients to meet certain age requirements, have a particular level of health insurance coverage, and undergo a supervised weight loss program before approving the surgery. Additionally, insurance companies may limit the number of weight loss surgeries that they will cover.

If you are considering weight loss surgery, the first thing that you should do is talk to your healthcare provider. They can help you determine if you meet the criteria for weight loss surgery and guide you on the next steps. Once you have confirmed that you meet the necessary criteria, you should contact your insurance provider to see if they cover weight loss surgery. You should also ask your healthcare provider to provide you with the necessary documentation to submit to your insurance company.

It is essential to note that insurance coverage can vary from state to state and plan to plan. Some insurance providers may cover all types of weight loss surgeries, while others may only cover certain types of surgeries. Additionally, some insurance providers may only cover specific healthcare providers for weight loss surgeries. Therefore, it is essential to do your research and read through your insurance policy to ensure that you understand what is covered.

If your insurance provider does not cover weight loss surgery, you still have a few options. You can contact the healthcare provider’s billing department and negotiate a payment plan. Some hospitals also offer financial assistance for patients who cannot afford to pay for weight loss surgery out of pocket.


Weight loss surgery can be an effective solution for those struggling with obesity. However, the cost of weight loss surgery can be a barrier for many people. The good news is that many insurance providers cover weight loss surgery for patients who meet certain criteria. The key is to do your research, understand your insurance policy, and work closely with your healthcare provider. With the right guidance and support, weight loss surgery could be a life-changing experience that improves your overall health and well-being.


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