Many people are unsure if they are “overweight enough” to be considered a candidate for weight loss surgery. Weight is, of course, a primary qualification; but there are also other factors. At the Nicholson Clinic, here are our qualifications for a LAP-BAND/REALIZE™ band, gastric bypass surgery, or gastric sleeve:
- A body mass index (BMI) of 40 or more (which translates to about 100 pounds overweight for men and 80 pounds overweight for women). OR
- A BMI between 30 and 39.9 with at least one serious obesity-related health issue such as heart disease, type 2 diabetes, severe sleep apnea, hypertension, etc.)
The patient should also meet these three conditions:
- Have been classified as obese for at least five years.
- Do not have a history of addiction or severe psychiatric problems.
- Have a thorough understanding of the weight loss surgery you have chosen and the lifestyle changes that are necessary for it be successful.
There are many states that have laws that require insurance companies to cover weight loss surgery if it is considered medically necessary and the patient meets the criteria set forth by the National Institutes of Health. Generally speaking, approximately 50% of insurance companies will cover a weight loss surgery including the LAP-BAND/REALIZE™ band, gastric bypass surgery, and gastric sleeve as long as the patient’s doctor provides a Letter of Medical Necessity.
A Letter of Medical Necessity is submitted to your insurance company and allows them to consider your request for surgery. The letter essentially addresses why weight loss surgery is critical for the health of the patient and why surgery is necessary. The Letter of Medical Necessity will include information such as the weight of the patient, including BMI, the number of years that the patient has been overweight, full medical history including conditions related to obesity, and diets and weight loss programs attempted by the patient in the past.
Of course, insurance coverage can be tricky business. Once you schedule an appointment, our insurance verifiers work with our patients step-by-step to provide their insurance company with what they need to help provide coverage.
Some insurance companies that currently provide partial or complete coverage of some weight loss surgeries include Blue Cross (in some states), Humana First Health, United Healthcare, Aetna, and Cigna.
However, be sure to check with your insurance carrier or human resource department to determine your specific insurance coverage for weight loss surgery.
We typically see patients with a body mass index (BMI) of 30 or more (which translates to about 100 pounds overweight for men and 80 pounds overweight for women).
At the Nicholson Clinic, if going the self-pay route, our qualification is typically a body mass index (BMI) of 30 or more. If using insurance, our qualifications typically include:
- A BMI between 30 and 39.9 with at least one serious obesity-related health issue such as heart disease, type 2 diabetes, severe sleep apnea, hypertension, etc.
- A history of obesity for at least five years.
- Patients may also need a pre-surgical psychological evaluation and dietitian appointment.
In our experience, the qualifying requirements are often:
- BMI over 40 -OR-
- BMI over 35 with one or more underlying health conditions (such as obstructive sleep apnea, coronary heart disease, medically refractory hypertension, or type 2 diabetes)
Coverage for your weight loss surgery is dependent on your specific insurance plan; and you will likely need to complete a few steps for coverage, i.e. complete a medically supervised diet program, schedule a psychiatric evaluation to obtain a mental health clearance letter, and schedule a nutritional evaluation from a Registered Dietitian. At the Nicholson Clinic, you will be assigned a Patient Care Advocate (PCA) to help you navigate this process.
While most major insurance carriers have bariatric coverage and will cover weight loss surgery if it is considered medically necessary and the patient meets the set criteria, it’s important to find out whether your specific employer group policy covers it. At the Nicholson Clinic, our insurance specialists will verify coverage on your behalf.
Patients should consult with their doctor as to which is the best weight loss procedure for them, based on their individual needs. Typically, gastric bypass patients lose 70-80% of excess weight after 12 months, and gastric sleeve patients lose up to 70% of their excess weight after 12 months.
We ask our patients who smoke to quit six to eight weeks prior to their weight loss surgery as smoking can complicate the surgical procedure itself and inhibit recovery.
Of course, we also encourage our patients to continue to avoid cigarettes in the long term as smoking does not fit with a new, healthier lifestyle.
Obesity can lead to a number of serious diseases and health complications such as diabetes, hypertension, sleep apnea, fatty liver disease, joint disease, GERD, heart disease, infertility and even certain types of cancer. Bariatric surgery, combined with a healthy diet and exercise, can reduce the risk of developing these health issues and eliminate them all together. Blood pressure and cholesterol levels can return to normal and patients may no longer need medications. Weight loss surgery can lead to a longer, happier, healthier, more active life.
Weight loss surgery decreases the body’s ability to absorb vitamins and nutrients and/or restricts the amount of food you can consume. This can result in malnutrition, or vitamin and mineral deficiencies, that can be damaging to your health. Therefore, all patients should take vitamins for life as recommended by their bariatric surgeon. In addition to vitamins and minerals, patients learn to eat smaller, healthier meals; eat food high in protein first, and maintain hydration. Your weight loss surgery clinic should provide post-op nutrition support and offer key points for healthy eating habits for lifelong success.
