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.
