Will Insurance Pay For Bariatric Surgery?

By Etwar McBean, MD, FACS

The Bariatric and Hernia Institute, PC

. http://www.tbhinstitute.com/

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Will Insurance Pay For Bariatric Surgery?

Insurance companies understand the importance of providing coverage for bariatric surgery, a life-changing procedure aimed at weight loss. However, it’s crucial to note that the coverage may vary across different plans within a particular company. For individuals considering this transformative surgery, it becomes vital to explore whether their enrolled plan offers the desired coverage. Furthermore, specific criteria need to be met to ensure approval of coverage from these plans.

Essential Requirements

Bariatric surgeries, including gastric bypass and sleeve gastrectomy, are typically reserved for individuals who are morbidly obese and experiencing health complications associated with obesity. Insurance coverage is generally provided when a person is at least 100 pounds over their ideal weight, indicated by a body mass index (BMI) of 40 or higher. Moreover, individuals with a BMI ranging between 35 and 40 can also qualify for coverage if they have obesity-related health issues like diabetes, hypertension, or sleep apnea requiring treatment.

Support From Primary Care Physician

Having support from a primary care physician is a crucial aspect, as insurance companies seek recommendations for bariatric surgery from personal physicians. This recommendation serves as a valuable validation for insurance coverage.

Documented History Of Weight Loss Efforts

To meet the requirements of most insurance companies, individuals must demonstrate a documented history of weight loss efforts. Bariatric surgery is typically not offered as the first line of treatment, making it necessary for patients to have previously engaged in a medically supervised weight loss program. This program can be overseen by a primary care physician, a weight management specialist, or a dietitian. Patients are expected to maintain a documented history of at least six months, with consecutive monthly visits. Those who demonstrate weight loss during this period are more likely to receive insurance coverage.

Psychological Evaluation

The insurance requirements include a comprehensive psychological evaluation to ensure that patients are mentally prepared for the life-changing procedure. This evaluation also aims to identify any underlying issues that may hinder the success of the surgery. By addressing these concerns beforehand, patients can have a clearer path to a successful outcome.

Additional Medical Evaluation

In some cases, patients may need to undergo additional medical evaluations, investigations, and procedures to determine their suitability as surgical candidates. For instance, a sleep study might be required to diagnose untreated sleep apnea. The evaluation process for bariatric surgery is usually outlined after a consultation with a specialized bariatric program.

Commitment To Long-Term Success

It’s crucial to understand that the results of bariatric surgery heavily depend on utilizing the procedures as tools and making a long-term commitment to lifestyle changes that promote weight loss and overall health. With a dedication to this transformative journey, individuals can maximize the benefits of the surgery and achieve a healthier and fulfilling life.