Standard requirements for weight loss surgery
Weight-loss surgery, also known as bariatric surgery, has demonstrated efficacy at helping people who suffer from obesity to achieve long-term weight loss and long-term health. Even though it may be able to help people lose weight, it is important to understand if you are a candidate.
There are two sets of requirements for weight loss surgery: national insurance requirements and clinical criteria.
National insurance requirments for bariatric surgery
- A body mass index (BMI) of 40 or higher
- A BMI of 35 or higher with a qualifying co-morbid disease (weight-related health problems) including type-2 diabetes, sleep apnea, high blood pressure, gastroesophageal reflux disease, intra-cranial hypertension, fatty liver, severe arthritis of joints or spine, or heart disease
- Having followed a medically-supervised weight loss program without success
List of common comorbidities
A comorbidity is a disease that develops as a result of a primary disease (in this case, obesity). Here’s a list of common comorbidities:
- Diabetes
- Cancer
- Hypertension (high blood pressure)
- Cardiovascular disease
- Respiratory conditions
- Metabolic disorders
- Congestive heart failure
- Fatty liver syndrome
- Gallbladder disease
- Depression
- Stress
- Menstrual irregularities
- Osteoarthritis
- Gastroesophageal reflux disease
- Sleep apnea
- Coronary artery disease
Why are there requirements for bariatric surgery?
Completing a medically-supervised weight loss program is a bariatric surgery requirement of many insurance companies. Because weight loss surgery costs several thousand dollars, insurance companies want evidence that you can follow a medically-supervised weight loss program, because that bodes well for your ability to stick to a strict diet and exercise regime after surgery.
Even if you do not plan to go through your insurance company for weight loss surgery, following a medically-supervised weight loss program is still highly recommended because it will help you transform your foundational lifestyle behaviors to yield the best possible weight loss and most life-lasting results.
What is BMI and how is it calculated?
BMI stands for body mass index and it’s a calculation based on your weight and height. Here’s how BMI is calculated:
BMI = kg/m^2. For example, if you weigh 265 pounds (120.2 kg) and you’re 5’ 9” (1.75m) then your BMI would be 37.
Here’s what your BMI means:
BMI < 18.5: Underweight
BMI = 18.5 – 24.9: Healthy weight
BMI = 25 – 29.9: Overweight
BMI > 30: Suffering from obesity
BMI > 40 (or over 35 with weight-related health conditions): Qualify for bariatric surgery
Calculate your BMI now
Clinical criteria for bariatric surgery
Bariatric surgery is a big adjustment to your system, both physically and mentally. As such, it’s important to ensure that you are fully prepared to handle these changes.
A key requirement for weight loss surgery is that before surgery you’ll need to undergo a series of consultations:
- Initial surgical physician consultation (to discuss your current health conditions and medications and identify which bariatric approach will meet your long-term goals the best)
- Psychological (behavioralist) evaluation
- Physical activity and fitness consultation (to create a pre- and post-surgery exercise plan)
- Dietiary evaluation
- Follow-up physician appointment ( may be needed in some cases to track progress toward the pre-operative plan)
- Preoperative visit with your surgeon
Why do these requirements for bariatric surgery exist?
These consultations will help you and your weight loss team to determine whether or not weight loss surgery is a good fit for you. The goal of these requirements for weight loss surgery is to pre-emptively identify any issues that would derail your weight loss journey or lead to safety concerns. You and your weight loss team can then work together to craft and implement solutions to help you reach your weight loss goals.
The psychological evaluation is important because weight loss surgery can exacerbate depression and suicidal thoughts in some patients. If you suffer from depression or have harmed yourself in the past, then it’s important to get treatment and to develop a support system so that you can alleviate the increased risk after surgery. This support system may involve visits to a specialized counselor or psychologist. Additionally, these visit will help to identify triggers for dangerous thoughts and behaviors and help you develop a plan to use alternate coping mechanisms.
Another key requirement for bariatric surgery is motivation. Even after weight loss surgery, patients need to be very diligent about maintaining lifelong lifestyle changes. You will need to remain committed to your dietary and exercise plan for the rest of your life in order to lose your excess weight and keep it off. As such, it’s essential that you’re 100% motivated to make and maintain these lifestyle changes; and these consultations can help assess and enhance your motivation.
Individual weight loss surgery requirements
At the Bariatric and Metabolic Center of Colorado (BMCC), we offer three bariatric surgical procedures: the gastric bypass, the gastric sleeve, and the loop duodenal switch.
We do not offer LAP-BAND® surgery (also known as gastric band surgery) at the BMCC because it is much less effective with a high failure rate, and carries a high risk of complications.
Some of the bariatric surgery requirements are the same for all procedures: having a BMI of over 40 (or over 35 with co-morbidities) and completing a weight loss program under medical supervision prior to surgery.
Some of the requirements are unique to the surgery type:
Gastric sleeve requirements
- No severe GERD or reflux
Gastric bypass requirements
- No inflammatory bowel disease
- Strong lifelong commitment to vitamin intake
Duodenal switch requirements
- For some insurances BMI >50
- No severe GERD or reflux
- No inflammatory bowel disease
- Strong lifelong commitment to vitamin intake
Gastric bypass requirements vs gastric sleeve requirements explained
The requirements for the gastric sleeve vary from the requirements for gastric bypass surgery which vary from the requirements for the duodenal switch.
Gastric bypass requirements
The gastric bypass, for instance, bypasses part of your small intestine and can inhibit vitamin and mineral absorption. As such, one gastric bypass requirement is to take daily vitamin and mineral supplements after surgery. While regular vitamin intake is recommended after all procedures missing a vitamin or two after a sleeve gastrectomy is not nearly as dangerous as inconsistency following a gastric bypass.
Gastric sleeve requirements
On the other hand, the sleeve can exacerbate heartburn, whereas the gastric bypass does not; so one gastric sleeve requirement is that you do not suffer from significant heartburn or reflux. If you do suffer from these conditions, then the gastric bypass will better serve you.
Learn more about each weight loss surgery:
Will insurance cover my bariatric surgery?
Many people wonder what the insurance requirements are for weight loss surgery. If you qualify for weight loss surgery, some individual insurance plans may cover it with as little as a $0 copay, and some won’t cover it at all. This all depends on your insurance plan and the state in which you live.
While commercial payers (eg. Anthem, United, Cigna, and Aetna) are allowed to provide plans in every state that remove bariatric benefits, some states mandate coverage for weight loss surgery on the state health exchange plans.
- Arizona
- California
- Colorado
- Delaware
- Hawaii
- Illinois
- Iowa
- Main
- Maryland
- Massachusetts
- Michigan
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Rhode Island
- South Dakota
- Vermont
- West Virginia
- Wyoming
Just because your state doesn’t require bariatric surgery coverage or you have a commercial insurance plan such as Anthem, United, Cigna, or Aetna, does not mean that your insurance won’t cover it. Most standard insurance plans in every state will cover weight loss surgery. However, your cost may vary depending on your specific health insurance plan. If you have an unmet deductible that needs to be paid before your insurance coverage begins or have a co-pay percentage to contribute, you may have to contribute this portion as an out-of-pocket expense.
What should I do if I qualify for weight loss surgery?
If you believe that you’re a good candidate for weight loss surgery, it’s important to talk to a qualified team of experts to determine what steps to take next.
At the Bariatric and Metabolic Center of Colorado, our team of experts is here to help you every step of the way. Go ahead and schedule an appointment with our friendly staff.
Meet your Bariatric Physician Dr. Joshua Long
MD, MBA, FACS, FASMBS
A nationally renowned and double-board-certified Denver bariatric surgeon, Dr. Long uses a partnership care model with each patient to tailor care to their individual needs. Patients routinely thank Dr. Long for his warm, compassionate bedside manner. He’s considered to be at the top of his field, having performed well over 2,000 surgeries in all places consistently throughout the site.