Will Insurance Pay for Weight-Loss Surgery if You LOSE Weight?

Ohhhh the joys of health insurance.

I will be upfront in saying – insurance coverage is not my speciality. However, I’ve worked in weight-loss surgery long enough to know (for the most part) how it works.

(Read more on Pre-Op Diets and Why You Shouldn’t Wait to Make Changes)

If you are going through an accredited ASMBS Bariatric Program, you will meet with a dietitian before and after surgery. When a patient gets started on a healthy eating plan that will start their weight loss before surgery might bring up the question, “will insurance deny me if I’m losing weight?”

Valid question. That seems like something they would do, doesn’t it!?

Actually. It’s the opposite. Some insurance companies will deny you if you GAIN weight while in your pre-op program. Wait…what?

Yes, insurance companies are catching on. Weight-loss before surgery has a decrease risk of complications, a shorter surgery time and hospital stay and patients statistically have better long-term success when they’ve lost weight BEFORE the operation day.

But I was told my BMI couldn’t go too low….

For some patients, this is absolutely true. For many others, it’s not as true as they think. Let me explain.

Most insurance companies will require you to have either a BMI above 35 plus a comorbidity (hypertension, diabetes, sleep apnea, etc) OR a BMI above 40 without a comorbidity.

SO – if you have sleep apnea and your BMI is right at 35…then yes…your program will probably instruct you to maintain your current weight and not lose any more. BUT if you have sleep apnea and your BMI is 38…you could lose some weight and still qualify.

You need to calculate your current BMI AND what weight you would be at for your “lowest approved” BMI.

There are plenty of websites online that you can plug in your height and weight and get the BMI. Let’s say you are 5’4 and weigh 250 pounds. You don’t have any co-morbidities and your program told you not to lose past a BMI of 40.

Your current BMI is 43 (if you are 5’4 and weigh 250 pounds)

You could lose 15 pounds before you were at a BMI of 40.

So? So you should make your goal to lose 15 pounds before surgery!

Why??

Your goal is to lose weight. The more you lose before, the closer you are to your goal after!

Patients who lose weight before surgery have a smoother transition to the post-op lifestyle and get more out of their surgery.

Studies show pre-op weight loss decreases risks of complications AND length of hospital stay

Studies are starting to show pre-op weight loss can result in a better overall weight-loss and keeping weight off in the long run

How weight loss surgery is similar to dating and marriage

Weight-loss surgery is such a MAJOR life change. I relate it to marriage.

Pre-op season = engagement

Surgery day = wedding day

Post-op Lifestyle = marriage

The more work you put in on the front end (premarital counseling, dating, asking the “big” questions”) the more confident you are when you make the lifelong commitment on the big day….AND the smoother the ride as you move into marriage :)

I hope that sums up the big question. For some of you, insurance requirements will mean you really shouldn’t lose weight before surgery. If that’s the case, focus on eating behavior changes and start cutting carbs out of your diet. Increase healthy fats (such as nuts) to prevent weight-loss but still focus on bettering your lifestyle. For the majority of patients – you CAN lose weight before surgery and you should!! By all means, talk with your programs insurance specialist to make sure you are fully aware of your own plan and coverage policies. 

For more information on pre and post-op living tips, be sure to join the Bariatric Food Coach or consider becoming a member!

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