Health Insurance and Gastric Bypass Surgery
While initially insurance companies were not anxious to cover the costs of bariatric or weight loss surgery, many companies are now realizing that it may be in their best interest to provide these surgeries under their coverage plans. Many western countries are experiencing an obesity epidemic and the number of obesity-related diseases is on the rise. People that are obese have increased rates of Type 2 Diabetes Mellitus, abnormal cholesterol, heart disease and stroke. Obesity is also associated with sleep apnea, breathing abnormalities and joint problems. When you combine the health care costs associated with all of the illnesses, including the cost of blood tests, long term medications and surgeries like coronary artery stents and angioplasty, insurance companies realized that is actually less expensive to pay for gastric bypass surgery than years of obesity-related diseases.
Health insurance carriers are still companies after all and many have set up specific criteria that patients have to meet before their gastric bypass procedure will be covered. Every insurance carrier is different, so you should check with your own insurance company if you are considering gastric bypass or another weight loss surgery. Patients usually must be of a certain weight to be considered for weight loss surgery. This is a guideline that surgeons use when selecting patients, but health insurance companies also use to determine eligibility for coverage. The surgical standard is a BMI (Body Mass Index) of 40 or higher or, if the patient already has an obesity-related disease such as Type 2 Diabetes, the BMI need only be 35 or above. BMI or Body Mass Index is determined by taking the patients weight in kilograms and dividing it by the patient’s height in meters squared. This obesity must be fairly long-standing and not a reflection of a recent rapid increase in weight. In addition, insurance companies want some indication that a diet and weight loss program has been faithfully attempted by the patient. This period can range anywhere from three months to two years depending on the insurer. Most surgeons look for this commitment as well and will advocate this type of intervention before they agree to perform gastric bypass surgery.
Insurance companies and weight loss surgeons want to make sure that patients are physically and mentally healthy enough for surgery. This may require the input of internal medicine physicians, psychologists and psychiatrists. These professionals may send formal letters to the surgeon as well as the health insurance carrier to certify a patient’s relative physical and mental health. Some companies require that patients are able to refrain from drugs, alcohol and smoking for a certain period of time before the surgery.
Some of the newer weight loss surgeries may not yet be covered until their effectiveness can be established. A common example of a weight loss surgery that may not yet be covered is sleeve gastrectomy. Despite initial reports that this weight loss surgery is safe and effective, many insurance carriers will not pre-authorize the procedure. Even older procedures may require a deductible for weight loss surgery (sometimes as high as $4,000) and many companies will restrict coverage to one weight loss surgery per patient lifetime.
Gastric bypass surgery can be a true blessing to those that benefit from it but gastric bypass insurance may be limited. It is always prudent to speak with your health insurance provider before gastric bypass or any weight loss surgery.
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