Steps to Bariatric Surgery
Qualifications for Bariatric Surgery:
- BMI ≥ 40
- BMI ≥ 35 and at least one or more obesity-related co-morbidities such as type II diabetes, hypertension, sleep apnea, and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease.
- Inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts.
American Society for Metabolic and Bariatric Surgery (ASMBS)
the story of Bariatric Surgery
The first operations designed solely for the purpose of weight loss were initially performed in the 1950s at the University of Minnesota. The jejunoileal bypass (JIB) induced a state of malabsorption by bypassing most of the intestines while keeping the stomach intact. Although the weight loss with the JIB was good, too many patients developed complications such as diarrhea, night blindness (from vitamin A deficiency), osteoporosis (from vitamin D deficiency), protein-calorie malnutrition, and kidney stones. The JIB is no longer a recommended bariatric surgical procedure.
The gastric bypass was initially developed in the 1960s and was based on the weight loss observed among patients undergoing partial stomach removal for ulcers. Over several decades, the gastric bypass has been modified into its current form, using a Roux-en-Y limb of the intestine (RYGBP). Initially, the operation was performed as a loop bypass with a much larger stomach. Because of bile reflux that occurred with the loop configuration, the operation is now performed as a “Roux-en-Y” with a limb of the intestine connected to a very small stomach pouch which prevents the bile from entering the upper part of the stomach and esophagus.
Gastric banding was first introduced in 1978 but was not perfected until 1983. Since these procedures do not involve an intestinal bypass, laparoscopic adjustable gastric banding (LAGB) is a procedure which induces weight loss solely through the restriction of food intake. For optimal results, strict patient compliance and frequent follow-up for band adjustments are required.
Will My Insurance Cover Surgery?
Most insurance policies have specific rules regarding Bariatric or Weight Loss Surgery. To determine if surgery is a covered benefit, call the Customer Service number on the back of your insurance card and ask your insurance provider.
As of July 2021, certain Aetna and Blue Cross plans do cover this surgery, as well as Alaska Medicaid and Medicare Part B. However, you should always contact your insurance carrier to confirm coverage and determine how much of the cost your insurance will cover.
What Do I Have To Do for Surgery?
While all insurance companies have their own rules for what a patient must do to meet the terms of “medically necessary” for insurance coverage, here are the basics:
- Lab tests including Lipid, CMP, CBC, A1c, and drug screenings
- Imaging studies including Chest X-ray, Abdominal ultrasound, Pelvic ultrasound (females), and Upper GI Series
- Other studies including Pulmonary Function Test (PFT) and EKG
- Psychiatric Evaluation and Clearance
- Dietary (Nutritionist) Evaluation and Clearance
More importantly, a patient must show that they have tried to lose weight and have not been able to. Your insurance company will require 3-6 months of “physician monitored weight loss” which is typically done with your primary care provider. The visit documentation must include your height/weight and that the physician counseled you on Diet and Exercise. Some companies are very specific about time limits and the number of visits.
For Example, as of July 2021:
- Aetna requires 12 visits within two years of surgery
- Alaska Medicaid requires 6 months CONSECUTIVE within one year of surgery
How Do I Get Started?
1. Contact your insurance company to determine coverage and thier requirements for surgery authorization (all insurances will require Prior-Authorization for surgery)
2. Work with your primary care provider to achieve your needed Physician Monitored Weight Loss visits
3. Have your primary care provider refer you to a bariatric surgeon for evaluation
4. Work diligently with your surgeon, primary care provider, and support team to meet the requirements of this new lifestyle Before, During, and After surgery
What's my BMI?