Insurance and Bariatric Surgery

Most insurance companies will cover Bariatric surgery if it is proven to be medically necessary with the exception that the policy contains no exclusions for morbid obesity.

There are two different kinds of exclusions.
1. (may read) Treatment for obesity including diet/exercise programs, medication, surgery, etc. with the exception of morbid obesity due to medical necessity.
2. (may read) Treatment for obesity including diet/exercise programs, medication, surgery, etc. including morbid obesity regardless of medical necessity.

Exclusion #1 does not include Morbid Obesity therefore Gastric Bypass or Gastric Banding is a covered benefit if patient meets insurance criteria.

Exclusion #2 does include Morbid Obesity therefore any treatment including Gastric Bypass or Gastric Banding is not a covered benefit regardless medical necessity.

Note: Some insurance companies may make an exception to exclusion #2 if patient meets medical criteria. Patient may have to appeal a denial (sometimes more than once) to get approval, but it is possible.

Insurance Criteria
Most insurance companies use a standard medical criterion called the Apollo Criteria. Bariatric surgery is considered medically necessary for the treatment of morbid obesity when all of the following conditions are present.

1. Must have BMI (Body Mass Index) exceeding 40 (or) greater than 35 and documentation of at least 3 of the following severe co-morbidities (or) 100 pounds over weight.
• Insulin dependent diabetes mellitus
• Severe hypertension requiring 2 or more medications
• Symptomatic cardiac disease currently requiring medical treatment
• Obstructive sleep apnea

2. Must be in the care of an attending physician for the treatment of morbid obesity for a minimum of 1 year and the same attending physician must state the patient is a candidate for bariatric surgery and is cleared for the operation.
3. The duration of morbid obesity as defined above in #1 must exceed 3 consecutive years.
4. Documented failure of a physicians supervised nutrition and exercise program including dietitian consultation, low calorie diet, increased physical activity and behavior modification. This participation must be documented in the patient’s medical record by the attending physician who supervised the patient’s participation. Nutrition and exercise program should have occurred for at least one year and within the past two years prior to the request for surgery.
5. Age of the surgical candidate should be between 18–60 years of age.
6. Pre-operative psychiatric consultation and approval with no contraindications to long term participation in follow up care.

Most insurance companies will require the following guidelines be met for approval of this surgery. We are committed to helping you meet these goals, but it requires much from you. It is VERY important that you stick to these guidelines and keep all appointments as specified.

1. Primary care physician (PCP) diet: Most insurance companies require a low cal (800-1,200 cal/day) diet personally supervised by your doctor for at least 6 consecutive months. You should check in with your doctor and follow up with him/her every month so that he/she can note your progress in your medical chart. If your PCP decides to send you to a nutritionist for this diet, it is still necessary to follow up with your doctor monthly to insure that the appropriate notes are in your medical chart. At the completion of the 6 months, we will require a letter and office notes from your PCP stating that he/she has personally supervised a low calorie diet (800-1,200) for the last six months, giving specific dates and any success you’ve made. This letter should be written/typed on the office's official letterhead.
2. Dietitian Consult: Most insurance companies require an evaluation/consult from a dietitian. A dietitian is on our staff and is available for pre-operative evaluations and education. The dietitian also follows patients long-term and is present at our monthly support groups.
3. Psychological Consult: Most insurance companies require a psychological consult. Local psychiatrists / psychologists have taken a special interest in our bariatric program and have devoted their time to work closely with the physicians and patients during pre-operative evaluations. These mental health professionals also participate in our post-operative support groups and are available after surgery to assist the patient in focusing on managing post-operative life changes.

All insurance companies require prior-authorization for bariatric surgery. In order to do this, a consult with a bariatric surgeon is necessary.

If you are seriously considering bariatric surgery, please call our office to set up a consult or print out the online questionaire and mail it to our office. Once we receive this information, our office will contact your insurance company and call you to set up an appointment.