Gastric bypass requirements: what does it take to qualify?

September 26, 2019

 

 

If you are considering weight loss surgery, you’re probably wondering what the requirements are for you to be a candidate for surgery. The requirements for gastric bypass surgery can differ depending on whether insurance is covering your surgery or if you are going with the self-pay option. 

 

The general requirements you must meet for gastric bypass surgery include:

 

  • Efforts to lose weight with diet and exercise that have been unsuccessful

  • BMI of 35 or more and a serious weight-related health problem, such as type 2 diabetes, high blood pressure, or severe sleep apnea

 

Insurance guidelines

 

The general guidelines for insurance to cover gastric bypass surgery include:

 

  • Body mass index (BMI) of 40 or higher

  • Or, a body mass index (BMI) of 35-39 and a serious weight-related health problem, such as type 2 diabetes, high blood pressure, high cholesterol or sleep apnea

  • Documentation in your medical records confirming that previous attempts at medical treatment for obesity have been unsuccessful

 

Your insurance may have other specific guidelines regarding physician-supervised attempts, such as a six-month time frame within the past two years. Your provider may have a more specific guideline that you may have to meet in order to qualify for the surgery. 

 

Insurance-specific guidelines may include: 

 

  • Attempted formal physician-supervised weight loss plan 

  • Psychological evaluation to rule out major depression that’s being untreated

  • Evidence that your primary care physician supports you getting the surgery and has seen you struggle throughout the years

 

Self-pay option

 

Self-pay is an option if insurance doesn’t cover your surgery or you don’t meet their requirements. Most times, this option can speed up the process to when you can actually have the surgery because some qualification requirements are less stringent. 

 

Since it’s usually pretty obvious a patient has struggled with their weight for many years, we don’t make them get all the weight loss documentation together or go through a formal six-month program as most insurance companies have them do. Also, if patients don’t have a history of psychological problems, we don’t make them do a psychological evaluation. 

 

In addition, the weight requirements for getting the surgery are less strict if you aren’t using your insurance company (i.e. BMI of >35 or BMI 30-35 with a serious weight-related health problem). The reason self-pay option weight requirements can be less strict is because a lot of the criteria that the insurance companies have in place for weight and co-morbidities are outdated. They are based on data from open bariatric surgery in the ’90s.  These surgeries were more risky, so patients had to be sicker (or heavier) to outweigh the risks involved with surgery.

 

Minimally invasive surgeries today, like laparoscopic or robotic-assisted, are much safer. Because there is so much less risk with our current techniques and vast experience, we accept self-pay patients in the 30-35 BMI range with a comorbid condition or greater than 35 BMI without a comorbidity.

 

Time frames

 

Time frames for when patients will be able to have surgery are very different between the insurance and self-pay options. It can take anywhere from 3 to 9 months to qualify for insurance coverage, depending on the pre-surgery weight loss program that they require you to complete. Whereas with self-pay, you can have your surgical consultation, program education, anesthesia evaluation, and surgery within 3 to 4 weeks. 

Contact Nashville Weight Loss Solutions for more information about gastric bypass requirements

 

Are you trying to diet and exercise on your own, but still not getting the results you want? Nashville Weight Loss Solutions offers a comprehensive range of proven weight loss programs to help, whether you need to lose 20 pounds or 200. Contact our office today to schedule a consultation!

 

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