As the number of Americans diagnosed as severely or morbidly
obese continues to grow, so does the need for gastric bypass surgery. Insurance companies are
increasingly aware of this medical need, and many have
integrated coverage for gastric bypass surgery into their
policies in cases where the surgery is deemed medically
necessary.
Prior to considering any sort of weight loss surgery
, you should make sure that you fall within the guidelines
as outlined by The National Institute of Health (NIH). Obesity,
in general, is determined by one's Body Mass Index (BMI). This
is calculated by dividing your weight in kilograms by your
height in meters squared.
Qualifying for Insurance Coverage
To qualify as an ideal candidate for gastric bypass surgery
under NIH guidelines, a patient's BMI must be 40 or higher.
(A BMI of 40 is roughly 100 pounds overweight for men and 80
pounds overweight for women.) A patient with a BMI between 35
and 39.9, who has been diagnosed with a serious obesity-related
health issue (e.g., severe sleep apnea, heart disease, or Type 2
diabetes), may be eligible for the surgery, as well. The NIH
also emphasizes that understanding every detail of the operation
and the changes within your own lifestyle that you will need to
make is of extreme importance.
Before deciding to move forward with gastric bypass surgery, you
should investigate the terms of your insurance coverage in
depth. Some insurance companies have made exclusions for
employers, meaning that your employer may have the option of not
covering the procedure even if it has been determined a medical
necessity.
Gathering Evidence
Your insurance company may require a physician's documentation
proving your history of severe or morbid obesity. Your primary
care physician can provide copies of your office visit records
that demonstrate ongoing weight issues. (Your insurance company
will only want to see specific visit records a letter from your
physician describing your ongoing obesity is not acceptable.)
Also, be sure to include documentation from both present and
past physicians who have treated you.
Your insurance company may also require you to submit all
records of medications your physician has prescribed to you for
the purpose of weight loss. Additionally, records from any diet
programs you have participated in may be useful. If you are
seeing a licensed psychologist or psychiatrist, or if you are
currently taking any prescribed medications for mental health,
you may be required to undergo a psychiatric evaluation to
qualify for insurance coverage for your gastric bypass surgery.
In addition, depending upon the type of insurance you carry, you
may be required to have a referral or stay within a network of
providers. Ask your insurance company for any information or
guidelines on coverage of obesity surgery. Your request for
coverage may be denied if you fail to provide the necessary
documentation, so you should research exactly what you need when
beginning the process.
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