Does Highmark Cover Bariatric Surgery?

Bariatric surgery can be a life-altering decision for many people who are battling obesity and related conditions and have not had success with other weight loss methods. Your journey to wellness through bariatric surgery starts with understanding your Highmark insurance plan coverage, eligibility requirements, and out-of-pocket costs and how they relate to your bariatric weight loss plan.

Highmark Bariatric Surgery Coverage

Most bariatric surgery types and coverage begin with the question of medical necessity. Each Highmark insurance plan and every type of bariatric surgery are different.

The only way to determine whether your Highmark plan covers the type of bariatric surgery that is best for you is to look at your coverage summary or contact Highmark member services. However, if your Highmark plan does not exclude bariatric surgery, you will still need to meet the definition of medical necessity, which includes the following:

• 18 years of age or older
• Body Mass Index of 40 or greater OR
• Body Mass Index of 35 or greater AND one or more comorbid conditions such as hypertension, heart disease, hyperlipidemia, diabetes, obstructive sleep apnea, nonalcoholic fatty liver, and more.
• Documented unsuccessful weight loss through approved nonsurgical methods.
• Psychological evaluation by a licensed mental health care professional
• Commitment to life-long follow-up and lifestyle changes.

Adolescents who have attained physiological/skeletal maturity may also be considered with additional eligibility criteria.

Bariatric procedures that may be approved for individuals meeting Highmark’s medical necessity criteria include:

• Laparoscopic adjustable gastric banding using an FDA-approved adjustable gastric band.
• Biliopancreatic bypass with duodenal switch (or open procedure) for individuals with a BMI of 50 or greater)
• Roux-en-Y gastric bypass (RYGB)
• Sleeve Gastrectomy (laparoscopic or open procedure)

Eligibility criteria for repeat or revised bariatric surgical procedures may have additional requirements.

What If My Bariatric Coverage Is Denied by Highmark?

It can be frustrating to work hard to complete all the steps required to meet Highmark’s eligibility criteria and then have your request for approval for bariatric surgery denied. However, now is not the time to give up hope. You do have options.

First and foremost, determine why your coverage was denied. It may be something as simple as a missing document. Next, if the coverage denial is a little more complicated, involve your bariatric center team in the process. They have the experience to navigate the complexities of insurance documentation and follow-up.

If all else fails, you can file a formal appeal through Highmark’s appeal process. You’ve fought hard to improve your health, make sure you use all the channels available to you.

Out-of-Pocket Costs to Consider

Even when you’ve checked all the boxes and have received insurance pre-approval for your bariatric surgery, there will still be some expenses that, if not understood upfront, can be an unpleasant surprise.

Out-of-pocket costs related to your Highmark plan coverage may include:

• Annual deductible. Most health insurance plans have an annual deductible that resets when your plan renews each year. This is a dollar amount that must be paid before your insurance starts paying. There are some exceptions, such as routine doctor’s appointments, that may have copays instead.
• Copays. Typically expressed as a set dollar amount the member pays, with the plan provider paying the rest.
• Coinsurance. Similar to copays, coinsurance is a percentage split between the member and the plan provider for the cost of covered services.

Amounts paid out of pocket for coinsurance and copays may be deducted from the annual deductible. That means that depending on the timing of your bariatric surgery and other medical expenses during your plan year, the amount you may have to pay out-of-pocket may vary.

Your Journey to Wellness Begins Now

Before diving into eligibility requirements, types of bariatric surgeries, or out-of-pocket expenses, the best place to start your bariatric surgery journey is a conversation with your trusted physician.

Your physician can refer you to a bariatric center that can help you determine if bariatric surgery is right for you and, if so, help you map out a clear path forward to help you achieve your weight loss and overall wellness goals.