If a patient goes through insurance, their qualifications are as follows:

The items below are the minimum necessary for approval of your weight loss surgery. (This is BCBS policy, which is what most insurance companies follow).  However, Medicare is straight forward in their process.  They only go by the BMI specifications listed below.

BMI Specifications

  • Body Mass Index (BMI) of 40 or greater OR…
  • BMI 35 or greater with co-morbid conditions, including but not limited to HTN on optimal drug therapy, cardiovascular disease, diabetes (must be treated with insulin or oral agents), pulmonary hypertension or severe obstructive sleep apnea (RDI of 50 or greater).
  • Documentation of participation in a physician-supervised program of nutrition and increased activity including dietitian consultation, low-calorie diet, increased physical activity and behavioral modification. The program must be for six consecutive months and must be within previous 12 months of the request for surgery. Documentation of program participation must appear in the medical record by the attending physician. Records must include comments by the physician regarding patient progress or lack of progress OR acceptable with medical record documentation of medical supervision are; Weight Watchers, LA Weight Loss, Jenny Craig, EatRight etc. Not acceptable are self-directed programs such as joining a gym, Atkins diet, calorie counting, low fat, cutting back, internet programs, etc.
  • Active participation and documentation of non-surgical methods of weight loss.
  • Diagnosed as morbidly obese for 3 years or more in medical records. A letter from the PCP and dated photographs will be considered in lieu of recorded heights and weights.
  • 18 years of age
  • Primary Care Physicians Letter (PCP Letter)
  • Consult and Recommendation for a surgeon from a bariatric surgeon.
  • Must stop smoking at least 8 weeks prior to surgery.

BMI Requirements

Some insurance companies vary on criteria.  Some only have a 3-month diet, some have no diet, and some have a 6-month diet.  The main thing is the BMI requirements…35 with a comorbidity and 40 without.  Now with Private Pay is different.  The Comorbidities do not have to be present.