As the number of
Americans diagnosed as
severely or morbidly
obese continues to grow,
so does the need for
gastric bypass surgery.
Insurance companies are
aware of this medical
necessity, and many have
added coverage for
gastric bypass surgery
into their policies in
cases where the surgery
is found to be medically
necessary.
Prior to considering any
sort of weight loss
surgery , you should
make sure that you fall
within the guidelines as
outlined by The National
Institute of Health (NIH).
Obesity, in general, is
determined by one's Body
Mass Index (BMI). This
is calculated by
dividing your weight in
kilograms by your height
in meters squared.
Qualifying for
Insurance Coverage
To qualify as an ideal
candidate for gastric
bypass surgery under NIH
guidelines, a patient's
BMI must be 40 or
higher. (A BMI of 40 is
roughly 100 pounds
overweight for men and
80 pounds overweight for
women.) A patient with a
BMI between 35 and 39.9,
who has been diagnosed
with a serious
obesity-related health
issue (e.g., severe
sleep apnea, heart
disease, or Type 2
diabetes), may be
eligible for the
surgery, as well. The
NIH also emphasizes that
understanding every
detail of the operation
and the changes within
your own lifestyle that
you will need to make is
of extreme importance.
Before deciding to move
forward with gastric
bypass surgery, you
should investigate the
terms of your insurance
coverage in depth. Some
insurance companies have
made exclusions for
employers, meaning that
your employer may have
the option of not
covering the procedure
even if it has been
determined a medical
necessity.
Gathering Evidence
Your insurance company
may require a
physician's
documentation proving
your history of severe
or morbid obesity. Your
primary care physician
can provide copies of
your office visit
records that demonstrate
ongoing weight issues.
(Your insurance company
will only want to see
specific visit records a
letter from your
physician describing
your ongoing obesity is
not acceptable.) Also,
be sure to include
documentation from both
present and past
physicians who have
treated you.
Your insurance company
may also require you to
submit all records of
medications your
physician has prescribed
to you for the purpose
of weight loss.
Additionally, records
from any diet programs
you have participated in
may be useful. If you
are seeing a licensed
psychologist or
psychiatrist, or if you
are currently taking any
prescribed medications
for mental health, you
may be required to
undergo a psychiatric
evaluation to qualify
for insurance coverage
for your gastric bypass
surgery.
In addition, depending
upon the type of
insurance you carry, you
may be required to have
a referral or stay
within a network of
providers. Ask your
insurance company for
any information or
guidelines on coverage
of obesity surgery. Your
request for coverage may
be denied if you fail to
provide the necessary
documentation, so you
should research exactly
what you need when
beginning the process.
