Below you will find some of the most common insurance qualification criteria that patients will have to meet to one degree or another. Please bear in mind that insurance requirements will vary between providers.
Excess Body Weight / BMI:
The first crucial criterion for qualification for bariatric surgery is the body mass index or BMI, a measure of weight versus height. The FDA has set guidelines on approved BMIs for bariatric surgery candidates. Generally speaking, patients with a BMI of 40 or over may qualify for any bariatric procedure, those with a BMI of 35 to 39.9 may qualify for any bariatric procedure if they have an obesity related disease, and those with a BMI of 30 to 34.9 may qualify for Lap-Band® gastric banding surgery if their obesity is accompanied by one or more related diseases.
History of Diet and Exercise:
Most insurance companies will consider bariatric surgery as a last resort for weight loss and disease resolution, however they will usually expect to see detailed diet and exercise log that proves that the patient has tried and failed at losing weight through traditional means. While diet and exercise is the safest way to lose weight, most plans ultimately fail and patients end up re-gaining the weight they lost over the long term.
Medical Weight Loss:
Many insurance companies will require that a patient undergo a medical weight loss program (physician supervised, nonsurgical) before they can qualify for surgery. Medical weight loss programs are designed to offer patients a framework within which they can learn to change their lifestyles and habits, all the while being supervised by a physician. Medical weight loss requirements may be up to six months or even a year.
Medicare & Medicaid:
Medicare and Medicaid also cover bariatric surgery and have their own set of criteria. Medicare and Medicaid patients should click on the following link to learn more about the unique requirements of the public health system. Learn more about Medicare & Medicaid for Bariatric Surgery.
Should a patient’s pre-approval be denied, it is not the end of the process. Oftentimes, a clerical error or an incomplete application has caused the denial, or simply, a few additional steps must be taken to reverse the denial. Appeals are available to anyone whose insurance denies coverage.
Individual insurance companies may have several more requirements of bariatric patients before they will approve or pre-approve a surgical procedure. Therefore, it is important that the patient contact their insurance company, first to make sure that the procedure is covered, and second to ensure that they have an accurate idea of what is required of them.