According to the American Society for Bariatric Surgery (ASBS), the number of weight loss surgeries increased from about 16,000 in 1992 to about 103,000 in 2003; the membership of surgeons in the ASBS increased from 258 in 1998 to 1070 in 2003.
Gastric Bypass Surgery - Insurance Coverage
With the rising health costs associated with obesity, insurance companies are recognizing the long-term financial advantages of covering weight loss surgery in qualified patients. If you have health insurance, there is a good chance that your insurance will cover gastric bypass surgery as long as you meet their eligibility requirements.
Insurance Coverage for Gastric Bypass Surgery
Although the specific requirements will vary between insurance companies, all of them have guidelines in place stating patient eligibility for gastric bypass surgery. Just because your health plan has weight loss surgery benefits, coverage is not automatic. For some people, gaining pre-approval for obesity surgery can be a very frustrating process. Weight loss surgery is an expensive and drastic operation and insurance companies want to make sure that prospective weight loss surgery patients have made serious attempts to lose weight thru other means. Ultimately, most insurance companies will cover the gastric bypass cost if it is a medical necessity and all other means of weight loss have been exhausted, but you have to be able to provide the proper documentation to support your request for weight loss surgery coverage.
Patient Criteria for Gastric Bypass Surgery
One of the most basic qualifications for gastric bypass surgery is a patient's Body Mass Index (BMI), a mathematical computation defining obesity based on a persons height and weight. Under The National Institute of Health (NIH) guidelines, an ideal candidate for gastric bypass surgery must have a BMI of 40 or higher. If you do not know your BMI, it is approximately 100 pounds overweight for a man or 80 pounds overweight for a woman. A candidate with a BMI of 35 or higher with obesity co-morbidities (such as diabetes type 2, heart disease, or severe sleep apnea) may also be considered for weight loss surgery. The NIH guidelines also state the importance of a patient's understanding of the weight loss procedure and commitment to making the necessary lifestyle changes (healthy eating behaviors and regular physical activity).
In addition to qualifying for gastric bypass surgery based on your BMI, weight, and other health conditions, insurance companies also want a documented history of weight loss attempts and a Letter of Medical Necessity from your primary care doctor and/or bariatric surgeon.
Documented Weight Loss Attempts
Insurance companies will usually request some sort of documentation showing a patient's history of obesity and methods of weight loss tried over the years. This is one area that varies greatly from insurance company to insurance company. Some insurance carriers will want to see six months of documented weight loss attempts, other insurance companies will require five years of weight loss records. Since weight loss surgery is considered the last step in weight loss, insurance companies want to see that an obese patient has seriously tried to lose weight using all other means available, including diet, exercise, and weight loss pharmaceuticals or medications. Some insurance carriers will accept records showing enrollment in a commercial weight loss program, such as Weight Watchers or Jenny Craig, but many other insurance companies will want to see participation in a medically supervised program. Usually, a patient considering gastric bypass surgery will have been obese at least five years and tried to lose weight under a doctor's supervised and documented weight loss program.
A Letter of Medical Necessity
A Letter of Medical Necessity is simply a statement written by your doctor outlining the reasons why weight loss surgery is medically necessary. It will include your weight, how long you have been overweight, a list of all your medical problems that are associated with obesity, medications you are taking, how you have tried to lose weight over the months/years but have been unsuccessful, and why he/she is advising weight loss surgery. Morbid obesity is a life-threatening disease, and the medical necessity of weight loss surgery is as a last resort life-saving attempt for the morbidly obese patient.
Additional Tests and Studies Necessary for Weight Loss Surgery Approval
There are several other tests and studies that are commonly expected from your bariatric surgeon and/or insurance company before approval is given for weight loss surgery. These include a nutrition consult, lab testing, and psychological evaluation.
Insurance Denials for Weight Loss Surgery
If your first request for weight loss surgery is denied, it may be possible to appeal the decision and win approval. While this is a discouraging set-back, find out the reasons for the denial and then proceed to satisfy the insurance requirements. Sometimes a denial is simply a matter of missing documents. While it is important to be personally involved in the process and persist on your own behalf, it is also helpful to work together with your doctor's insurance coordinator who can offer you advice and assistance in getting insurance approval.
Insurance Exclusions for Weight Loss Surgery
If your insurance plan does not cover weight loss surgery for obesity, it may still be possible to appeal. Some weight loss surgery patients have been able to gain approval for gastric bypass surgery as a treatment for other medical conditions, such as diabetes type 2 or severe sleep apnea, that are usually covered conditions. A doctor who is experienced in bariatric surgery and is familiar with insurance company requirements, may be able to help you appeal to your insurance company and gain coverage for the bariatric procedure, even if it has an exclusion for obesity surgery.
Legal Assistance for Weight Loss Surgery
If you and your doctor's office have done all that you can do, but the insurance company still refuses to cover gastric bypass surgery, it may be appropriate to seek legal assistance. The Obesity Law and Advocacy Center may be able to assist you in getting insurance approval for weight loss surgery and/or offer you helpful advice. If you are struggling with coverage issues, you may also want to consider joining the Obesity Action Coalition, a national group supporting the rights and needs of obese people.
Medicare and Medicaid Coverage for Gastric Bypass Surgery
Medicare and Medicaid will cover the cost of gastric bypass surgery for qualified beneficiaries if the procedure is performed in a Center of Excellence facility. A Center of Excellence is a facility certified by the American College of Surgeons or the American Society for Bariatric Surgery as a health care provider in which highly qualified surgeons perform a large number of bariatric procedures and have a high level of results. Seniors and adolescents may even be considered for the procedure under certain circumstances. Prospective patients who meet the NIH guidelines for weight loss surgery and are interested in gastric bypass surgery should contact their regional Medicare of Medicaid office for more information.
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