Gastric Bypass:  When is it covered?

Overweight and obesity is a major health crisis in North America. More and more adults and children are struggling with the weight and the array of health problems that is associated with carrying around dangerous and unwanted pounds. The weight loss/diet industry is a multi-billion dollar business, with desperate people willing to try anything from books to commercial diet plans and pills in order to lose weight for health and beauty reasons. One of the more drastic and expensive weight loss treatments is gastric bypass surgery. This controversial surgery can be life-saving, life-changing or life-taking, but it always costs a lot and not everyone can afford the multi-thousand dollar price tag which begs to question: will my insurance company pay for gastric bypass surgery?

Gastric bypass surgery is an extremely invasive procedure that involves shrinking the stomach so that only a small pouch remains. Effectively, patients that have undergone successful gastric bypass surgery are unable to eat more than a few tablespoons of food at a time. The technique has been proven effective for quickly reducing the mass of morbidly obese people for whom regular activity and nutritional monitoring has not worked. The surgery is not a quick fix for minor weight loss, however.  It is a serious procedure applied in only serious cases. To qualify for the surgery, whether covered by health care insurance or not, you must have a body mass index (BMI) greater than 40. For an average man, that means about 100 pounds overweight and 80 pounds over weight for an average woman. Individuals with a slightly lower BMI may also be considered for gastric bypass surgery if they also have a serious condition, such as diabetes or heart disease that can be worsened by obesity. Surgery candidates must also realize the severity of changes gastric bypass surgery will mean in terms of lifestyle changes and responsibility.

In cases where gastric bypass surgery is deemed medically necessary, most health care insurance companies will pay for the procedure, even if the initial application is refused. If you have to fight to have the surgery covered, arm yourself with information and support from your physician, along with any information you can gather about the potential savings in future medical costs as a result of the weight you would lose if the surgery is carried out. There are abundant studies from reputable organizations that trumpet the benefits of weight loss to the prevention and reduction of several associated problems such heart attack, stroke, Type 2 diabetes (so-called adult-onset diabetes), and sleep apnea to name a few.

Even though most insurance companies will agree to fund gastric bypass surgery that has been deemed necessary, there are some plans that do not pay for it or will do so under certain circumstances only. These circumstances, like proven attempts to lose weight in other ways, may need to be authenticated by your physician. Review your policy to find out exactly what coverage you qualify for, or speak to your insurance provider for a more precise explanation. Get the information in writing, if possible.

Even if you are the perfect candidate for surgery, do not expect a quick process. Between the time you contact your insurance provider about possible gastric surgery and the time you actually get the surgery, many months may have passed.

While it can act as a catalyst for fantastic weight loss, gastric bypass is a serious surgery, and as a result, you may be at risk of post-operative complications ranging from mild infection or discomfort to digestive issues. One study has produced the alarming statistic that up to 98 percent of gastric bypass recipients experience at least one post-operative complication or side effect. It is important that you know, in advance, how your health insurance provider would handle any costs associated with post-operative complications associated the bypass surgery. Will you receive blanket approval for any additional care that may be necessary or will you have to secure case-by-case approval for each new procedure or measure?

Once again, gastric bypass surgery is a potentially dangerous procedure that requires serious thought and consideration. Health insurance coverage may be one of the elements of your decision, but it shouldn’t be the only thing you think about.