Am I a Candidate?
Qualification criteria for bariatric surgery was created based on National Institute for Health’s consensus paper for bariatric surgery, which factors in one’s BMI (body mass index) and the existence of diseases associated with obesity. History shows us that adults who are approximately 75 pounds overweight and are experiencing health issues such as hypertension, diabetes, heart disease, obstructive sleep apnea and GERD to name a few, or adults whose BMI score is 40 or higher (100 pounds or greater in excess), with or without obesity related diseases, have less than a 5% chance with medical intervention alone to achieve and sustain their weight loss/health gain. Depending on the degree of severity, the risks of one’s health issues may significantly outweigh the risk of surgery and therefore be of benefit. You may calculate your own BMI score on the tool provided in the right column.
Your Solution at Texas Health Presbyterian Rockwall believes that surgery may be a consideration if your BMI range is between 30 and 35 and you currently are experiencing obesity health related issues. BMI’s from 30-35 is considered a preventative intervention and therefore is not covered by insurance, and careful assessment of risk verses benefit of surgery should be established in order to proceed with surgery. BMI’s of 35 or greater will follow NIH guidelines for qualifying for bariatric surgery. Your Solution is established to serve those from 21-64 years of age. However, adults ranging from 18-21 and those greater than 64 will be addressed on a case by case basis.
In general, most insurance companies have based their qualifying criteria on the NIH guidelines. Employers may elect to add additional qualifying criteria to the insurance plan they provide. It is important to understand your specific company’s policy. The following are examples of how plans may vary:
Body Mass Index: Insurance companies use this standard measurement to determine eligibility.
Medical Necessity: Is this procedure being performed because the patient’s health is deteriorating to a dangerous point? Documentation of diseases associated with morbid obesity will be required. If the insurance company deems the surgery to be primarily aesthetic or cosmetic, they will likely disapprove you.
Diet and Exercise History: Has the patient made a concerted effort to lose weight through traditional means? A detailed log of eating habits and exercise regimens may be required for up to 6 months or more. When applicable, you may be asked to undergo a medical weight loss program of 6 months or more before you can qualify.
Appropriate Surgical Risk: Do the benefits of the surgery outweigh the risks? Serious medical problems including cardiac, pulmonary and abdominal issues may preclude you from qualifying for weight loss surgery. You will have to undergo various tests before surgery to make sure you are an appropriate candidate.
Type of Procedure: Some insurance companies only cover certain procedures. Most insurance companies cover gastric banding, but not all cover the gastric sleeve procedure.
Medicare and Medicaid: Most plans provide coverage for surgery, however, they require you to have those services provided at a Center of Excellence facility. Visit www.cms.gov and www.asmbs.org for more information.