Almost all bariatric surgeons and insurance companies follow the concept of medical necessity when determining if a patient qualifies for bariatric surgery. While a patient may be overweight and need to lose weight, it does not always indicate that bariatric surgery is the appropriate treatment. Bariatric surgery involves making substantial, and usually permanent, changes to the body's digestive system. It should be considered the treatment of last resort, not the initial recommendation.
Determining Medical Necessity
The concept of medical necessity is generally defined as "necessary and appropriate treatment that meets the standards of good medical practice in the medical community for the diagnosed condition." Although bariatric surgery is considered an effective treatment for morbid obesity, other weight loss methods can be effective as well, including monitored diet programs, exercise programs, weight loss medications, and medically-supervised weight loss programs.
In most cases, for bariatric surgery to be determined medically necessary, individuals must not only meet patient criteria for weight loss surgery, but are expected to first make serious attempts to lose weight through non-surgical methods. Many insurance companies will often require documentation showing at least a six-month history under a medically-supervised weight loss program before considering bariatric surgery medically necessary.
Patient Criteria for Bariatric Surgery
Most bariatric surgeons, LAP-BAND providers, and insurance companies, including the Medicare and Medicaid programs, follow the guidelines set by the National Institutes of Health (NIH) when considering a patient for bariatric surgery.
The NIH guidelines for bariatric surgery:
- BMI of patient is 40 or higher (morbidly obese), or
- BMI of patient is between 35 - 40 with obesity comorbidities
BMI is a measurement of a person's body mass index, based on height and weight.
Obesity co-morbidities are medical conditions associated with obesity, including high blood pressure, type 2 diabetes, heart disease, and severe sleep apnea.
If you do not know your BMI, as a general rule, men who are at least 100 pounds over their ideal weight or women who are at least 80 pounds over their ideal weight, are considered candidates for bariatric surgery.
Weight Statistics of U.S. Adult Population
Letter of Medical Necessity
A Letter of Medical Necessity is a statement written by a patient's doctor describing a patient's health condition and the reasons why bariatric surgery is the necessary treatment. The letter is required by most insurance companies when an individual is requesting pre-authorization for insurance coverage of bariatric surgery. The letter usually includes a patient's weight, body mass index (BMI), how many years the patient has been overweight/obese, overall health, obesity co-morbidities, previous weight loss attempts, documentation of a medically supervised weight loss program, and health history. It also states the doctor's recommendation for bariatric surgery as the medically necessary method of treatment.
Insurance Coverage for Bariatric Surgery - Need for Medical Necessity
Most insurance companies will provide coverage for bariatric surgery IF the patient meets patient criteria and medical necessity is established. To establish medical necessity, it is important to provide the insurance company with the proper documentation, including a Letter of Medical Necessity from your doctor.
Other documentation that should be included in your pre-authorization request are records and receipts for participation in a medically supervised weight loss program, receipts for enrollment in weight loss programs (such as Weight Watchers or Jenny Craig), exercise programs, nutritional counseling, diet books, exercise equipment, gym memberships, and medical visits.
If the documentation is relevant, don't worry about sending in too much information. Since you are trying to establish medical necessity for bariatric surgery, it is necessary to show that legitimate efforts have previously been made to lose weight but have been unsuccessful.
Insurance Denial for Bariatric Surgery - Lack of Medical Necessity
Insurance requests for bariatric surgery are often denied because the insurance company determines that there is a lack of medical necessity. Generally, a procedure is considered a medical necessity when it is needed to treat a serious or life-threatening medical condition and there are no other effective treatments available. An advanced procedure or treatment, such as bariatric surgery, is not considered medically necessary if less invasive, less expensive treatments (diet, exercise, weight loss programs) are not tried first.