Pathway to Surgery
Am I a Candidate?
The medical community and your insurance company use a term called Body Mass Index, or BMI, to determine your overall health risk related to your weight. BMI is a formula that calculates the ratio between your height and weight.
BMI 40 and Above
A BMI of 40 or greater indicates morbid obesity and puts you at the greatest risk for obesity-related health conditions such as diabetes, sleep apnea, high blood pressure, osteoarthritis, heart disease and premature death. All bariatric procedures are offered in this BMI range.
BMI 35 to 39.9
This category is considered severe obesity and still places you at high risk for obesity-related health conditions and premature death if left untreated. All bariatric procedures are offered in this BMI range as well, especially if you already have diabetes, high blood pressure, high cholesterol, sleep apnea, or severe osteoarthritis.
BMI 30 to 34.9
Patients in this BMI range are considered obese. Their health risk is still high and certain lower risk procedures can be considered in this range. The FDA has approved the Gastric Balloon and Gastric Banding procedures for BMI > 30 but insurance companies have not adopted these recommendations, so these patients have to chose the Self-Pay FastTrack option. Occassionally, the Gastric Sleeve will be considered in this lower BMI range, however it is considered off-label use in this situation and requires the Self-Pay option as well.
BMI 25 to 29.9
This BMI falls into the overweight category and still puts you at increased risk for disease, particularly if your body fat is concentrated around the abdomen. Bariatric procedures are not offered in this BMI range, however Weight Loss Medications or programs like the Ideal Protein Weight Loss Method are great options to gain control of your health and improve your overall quality of life.
Will My Insurance Cover Bariatric Surgery?
Small companies and private insurance policies do not cover bariatric surgery, however many large employers do provide coverage for their employees. The easiest way to find out if your employer provides coverage is to call your human resources department or call the number on the back of your insurance card and ask if they cover Bariatric Surgery. You may also fill out our contact form and someone from our office will assist you.
If you have bariatric surgery coverage and your BMI is > 40 (or > 35 with a life threatening co-morbidity like diabetes, high cholesterol, or sleep apnea), then you can be considered for either a Lap-Band, Gastric Sleeve, Gastric Bypass, or Duodenal Switch. In addition to BMI, most insurance companies require other criteria to be met prior to agreeing to cover the surgery and may include:
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Documented dietary attempts ineffective
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No unstable or untreated psychological illnesses
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Not a smoker or willing to quit smoking prior to surgery
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Primary care physician letter of support
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Multi-disciplinary program or Center of Excellence designation
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Commitment to life-long medical surveillance
Next Step
All of Dr Houston’s surgeries are performed through the Centennial Center for Weight Management at TriStar Centennial Medical Center. If you know you have bariatric surgery coverage and meet the BMI criteria, then the next step is to Register as a New Patient with the Center to start the insurance verification and pre-approval process. The Centennial Center for Weight Management has dedicated insurance specialists that will help you navigate the process. They will:
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Verify your insurance benefits and criteria specific to your plan
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Provide the estimated out of pocket amount based on your insurance coverage
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Obtain medical records, referral letters and any other documentation required by your insurance
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Work with your insurance company to obtain approval for surgery
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Direct you for appropriate timing of your consultation with Dr. Houston
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Keep you informed and updated every step of the way
If you do not have bariatric coverage and wish to proceed with the Self-Pay FastTrack Option, please call us at (615) 342-5820 to schedule a consultation with Dr. Houston.