What are the typical requirements for surgery?

Hello! My doctor made a referral for me to have WLS, specifically telling me that I would benefit from VSG. Originally, my insurance several months ago did not cover the surgery- - but I recently got married and have new insurance that does cover it!

I'm excited to get this process started, as I've been told that it's sometimes 6 months to a year away. My paperwork has been sent to the surgeon and I'm waiting for an appointment to be seen (where I will be asking questions too) but I've seen how supportive this community is with one another, I figured you might be able to share some of your experiences with me. :)

TIA!

The short answer is, insurance generally requires a BMI over 40, or a BMI over 35 with either one or two comorbidities, such as Type 2 diabetes, sleep apnea, or a few other things.

After that, there are a million variations. Some require that BMI number to have been documented by a doctor from 1 to 5 years prior to approval. Some require a six month doctor supervised diet and weight loss program. There are a million other things, but you won't know what your specific policy requires until you ask them.

Then, there are requirements by the surgeon. They may have their own diet or nutrition program or classes they will make you follow. Some test for nicotine and other drugs. Etc.

There are a million possibilities.

Goodness! I didn't realize there was a bunch of different things! I know that I do qualify, even though my BMI is currently at 35...it's been higher over the years as well, but I have PCOS, diabetes, high blood pressure and sleep apnea-- the main reason for WLS is to hopefully put my diabetes into 'remission,' even if it's just for a short time.

Thank you for your response!

Don't hesitate to call the insurance company yourself. They all require something a little different, from a diet to a psych evaluation, whatever. Some will hook you up with a case worker to walk you through each requirement. Whatever you do, don't trust your surgeon's office to know what every company requires. If I depended on them, I'd have wasted 6 months on a diet that wasn't necessary.

Since your BMI is 35 you should be very careful about whether you lose weight on the typically required 3-6 month diet. Some insurance companies only require that your BMI be 35+ on the day of your surgeon consult and will still cover the surgery if you lose down to BMI 30+ on the supervised diet, but some will require the diet but not cover the surgery if you at any point dip below BMI 35.

For the insurance side of things, I recommend calling the number on the back of your card and asking them directly. (And seriously, do this. Don't trust any of your doctors to tell you what your insurance requires.)

For me, my insurance required a psych eval. That was it. My surgeon required an upper endoscopy. And then I had the typical BMI 40 with no comorbidities, 35 BMI with comorbids that Grim mentioned.

I called the insurance company, but when I called I didn't ask for the requirements. I may have to give them a call back.

Thank you for your response! :)

My insurance really puts you through the ringer. In addition to the BMI/comorbidity requirements others have discussed, I had to:

have a psych eval

go to 2 WLS classes, and 1 group nutrition class

see a nutritionist 1:1 monthly for 6 months, and show compliance with diet and exercise.

Go to two of my surgeons information sessions

An upper GI, H.pylori test.

Got clearance from PCP, and all specialists that I see.

Provide operative reports for all abdominal surgeries I've had.

Sleep study and documented compliance with C-PAP (literally they read a chip in my machine)

It was pretty grueling!

Since the goal is to put Type 2 into remission, I would insist on RNY. It has an 85% success rate, compared to 50% for VSG.