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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 typically do not cover bariatric surgery unfortunately. However, many large employers do provide coverage for their employees.  

If you have bariatric surgery coverage, insurance companies require a BMI > 40 (or > 35 with a life threatening co-morbidity like diabetes, high cholesterol, or sleep apnea). In addition to BMI, insurance companies may have additional requirements to be approved for surgery and may include:

  • Documented dietary attempts ineffective 

  • No unstable or untreated psychological illnesses

  • Not a smoker or willing to quit smoking prior to surgery

  • Primary care physician letter of support

  • Multi-disciplinary program or Center of Excellence designation

  • Commitment to life-long medical surveillance

What is my Next Step?

To find out if your insurance plan covers bariatric surgery, please complete our Contact Us form. Our insurance specialists will contact your insurance company to verify your benefits. Once we know the details of your insurance coverage, our patient navigator will call you to discuss the next steps.  

 

If you do not have coverage for bariatric surgery and wish to proceed with the Self-Pay FastTrack Option, please call us at (615) 342-5820 or complete our Contact Us form to schedule a consultation with Dr. Houston.  

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