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Tag Archives: insurance guidelines for weight loss surgery

How do I know if I qualify for weight loss surgery?

Posted on March 05, 2018 by

gastric sleeve sleeve gastrectomy GeorgiaIf you are at least 50 pounds over your ideal body weight and have been unsuccessful with other methods of weight loss, you may be a candidate for weight loss surgery.  However, most insurance companies additionally require a BMI of 40 or greater or a BMI of 35-40 with other potentially life threatening health problems such as diabetes, high blood pressure and/or sleep apnea.  Your BMI is your weight in relation to your height.  So how do you calculate your BMI?  You need to take your weight in kilograms and divide by the square of your height (meters).  For example, If your weight is 80 kilograms and your height is 1.8 meters, you would square your height (1.82=3.24) and then divide it into your weight (80 divided by 3.24 = a BMI of 24.69).  Or you can simply enter your information online for quick results with a BMI calculator.4

General BMI classification guidelines include:

BMI Classification Health Risk
Under 18.5 Underweight Minimal
18.5-24.9 Normal Weight Minimal
25-29.9 Overweight Increased
30-34.9 Obese High
35-39.9 Severely Obese Very High
40 and Over Morbidly Obese Extremely High

The decision as to whether or not weight loss surgery is right for you is ideally made by you and your surgeon after careful consideration of your weight, your past medical/surgical history and your current health problems or co-morbidities.  However, there are general guidelines that most surgeons and insurance companies adhere to when choosing who an appropriate candidate for weight loss surgery is as noted below:

General Guidelines for Weight Loss Surgery Candidates3:

  • BMI of 40 or greater
  • Comorbidity: You have a life-shortening disease process, heart disease, diabetes or obstructive sleep apnea that can be improved by losing weight.
  • For at least two years, you have attempted to lose weight.
  • You have been obese for an extended period of time, at least three to five years.
  • You are able to effectively care for yourself and follow a physician’s instructions.
  • You are motivated to lose weight and maintain a healthful lifestyle.
  • You do not abuse drugs or alcohol.
  • You are a nonsmoker or have quit smoking.
  • You are an adult under the age of 65.

These guidelines vary by insurance carrier and your individual policy.  Your insurance policy is an agreement between you and your insurance provider.  However, if you are working with an experienced bariatric surgeon/center, they can easily help you navigate through your particular insurance requirements and efficiently submit your information for surgery authorization. This topic is covered in Chapter 6 of the book, Less Weight…More Life! Is Weight Loss Surgery Right for You?

As with any general guidelines, there are caveats that cannot be ignored. Some of the ones we find most important include age, motivation and mindset.  With regards to age, you can see by the general guidelines listed previously that it is recommended that an adult be under the age of 65.  At the Center for Weight Loss Success (www.cfwls.com) we do not put a cap on age for good reason.  Age is just a number.  You likely know someone who is over 65 years of age yet physically, emotionally and intellectually they are really more like a 40 year old.  Conversely, you likely know someone around 40 who walks, talks and acts as if they should be 80+ years old.  In terms of lower age restrictions, although there are a few centers in the United States performing weight loss procedures on patients under the age of 18, most surgeons prefer to wait until you are 18 years of age or older and able to better decide and commit to such a life changing procedure.

Of great importance is your motivation and mindset.  If you are considering weight loss surgery, you need to be motivated and an active participant throughout your entire pre-operative and post-operative phases.  This is how you will experience the best results.  Weight loss surgery is something you need to do for yourself, not someone else.  You need to prepare yourself physically and mentally prior to surgery and proactively plan for your post-operative phase.  If you believe surgery is a “quick fix” or the “easy way out” you likely should not pursue weight loss surgery.  With this mindset, you may not fully commit to the lifestyle changes that result in the rewarding outcomes that will transform your life in so many positive ways.  However, if you do commit, get ready for an amazing journey.  Try not to get overwhelmed here.  An experienced bariatric surgeon/center will provide a comprehensive process to help guide you through these considerations.

Finally, it is important to note that some people are actually too obese to qualify for weight loss surgery.  If you are too heavy, you will usually be instructed to lose weight before your surgeon can proceed with weight loss surgery.  Once again, an experienced bariatric surgeon/center will guide you through this process and help you optimize your physical and emotional health prior to surgery and beyond.

3 Bariatric Surgery for Severe Obesity. Consumer Information Sheet. National Institute of Diabetes and Digestive and Kidney Diseases. March 2008. http:// http://win.niddk.nih.gov/publications/gastric.htm

4http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html

If you don’t qualify for weight loss surgery under your insurance provider, contact my Surgical Coordinator, Cat Williamson at CFWLS to discuss your options.