Am I a Candidate for Weight Loss Surgery?

• Am I Obese?
• Am I a Candidate?
• The Consultation
• Your Decision
• Paying for Weight Loss Surgery

Am I Obese?

Obesity results from the excessive accumulation of fat that exceeds the body's skeletal and physical standards. Severe obesity, sometimes known as "morbid obesity", is defined according to the Metropolitan Life Insurance Company height and weight tables as being 100 pounds or 100 percent above ideal body weight (IBW). According to the National Institutes of Health, an increase in 20 percent or more above your ideal body weight is the point at which excess weight becomes a health risk.

Today 97 million Americans, more than one-third of the adult population, are overweight or obese. An estimated five to 10 million of those are considered morbidly obese. According to the New National Heart, Lung, Blood Institute obesity guidelines, Body Mass Index (BMI) is the best known assessment of a person’s obesity since it is simple to use, accurate in determining the degree of obesity, takes both height and weight into consideration and applies to both men and women.

BMI is used extensively in managing surgical weight reduction.

Calculate your BMI  

What does it mean?

• A BMI from 18.5 through 24.9 indicates a healthy weight.
• A BMI from 25.0 through 29.9 indicates an overweight condition.
• A BMI from 30 through 39.9 indicates moderate obesity.
• A BMI of 40 or above indicates severe obesity.

Am I a Candidate?

You are a candidate for surgical weight loss if you:

• Have a BMI greater than or equal to 35 with one or more significant obesity related conditions including:
  • High blood pressure
  • Diabetes
  • Arthritis
  • Sleep apnea
  • Obesity hypoventilation syndrome
  • High cholesterol
  • Psudotumor cerebri
  • Family history of early coronary heart disease
• Other possible indications for patients with BMI's between 35 and 40 include:
  • Obesity-induced physical problems interfering with lifestyle (e.g. joint disease treatable but for the obesity
  • Body size problem precluding or severely interfering with social life, employment, family function, and ambulation).
• Have a BMI greater than 40 regardless of the presence of other medical condition
• Are 20-60 years old (with some exceptions)
• Have failed multiple attempts with supervised dietary, behavioral and medical therapy
• Understand and accept the operative risks
• Have realistic expectations and are motivated
• Are capable of understanding the procedure and its implications
• Have a lifelong commitment to lifestyle changes and long-term follow-up

The Consultation

• The First Appointment
• Pre-Operative Visit

Our multidisciplinary consultation process involves a thorough patient evaluation through an initial questionnaire that will be mailed to you prior to your clinic visit.

Our goals in the consultation appointment are three-fold:

• To educate patients regarding basic information about gastric bypass including the regimen after surgery, and risks and benefits of the operation
• To gather information regarding your height, weight, history, and medical conditions in order to determine appropriateness of patient for surgery
• To determine if there is a need for further evaluation prior to surgery (sleep study, cardiac evaluation, etc.)

The First Appointment
Prior to your arrival at the office, you will be asked to fill out an information sheet and a detailed questionnaire about your weight history and current medical condition.

You should bring:

• Your insurance card
• A list of current medications and dietary supplements
• The names/addresses of physicians who have taken care of you in the past
• Any other medical data relevant to your clinical evaluation

Please come early to the appointment to complete the paperwork.

After watching the informational video, you will have an interview with (and be examined by) a surgeon. He will discuss and clarify your medical history, conduct a physical examination, and go into a detailed discussion about gastric bypass surgery in your specific case. He will let you know if you are a reasonable candidate for gastric bypass to ensure that you are as informed as possible about the procedure and its ramifications.

If your surgeon determines you are an appropriate candidate for surgery, he will make a written request to your insurance company to approve coverage for obesity surgery. Further consultations may be necessary to ensure your health is stable and you can undergo general anesthesia for the surgery. These may include appointments with a cardiologist, psychologist, and internist, as well as tests including sleep study, endocrine evaluation, etc.

Pre-Operative Visit
The patient usually sees the surgeon again after all the pre-operative medical testing is completed (typically within two to three weeks before the date of surgery). The purpose of this appointment is to review all the medical data and make sure that the necessary testing has been done, and to answer any questions you may have. The surgeon and patient will also discuss possible medication changes and other pre-operative instructions.

During this visit to the hospital for pre-operative testing, you will also be oriented to the hospital admitting area, what time you would arrive on the day of surgery, and the ward in which you will recover from surgery.

If your spouse or other loved ones were not able to attend the first appointment, they are highly encouraged to come to this one. We encourage family members to be fully informed about the surgery.

Your Decision

The decision about whether to undertake obesity surgery is fairly complex and most importantly very personal. You must understand that weight loss surgery is a major undertaking and though most patients enjoy an improvement in obesity-related health conditions (such as mobility, self-image and self-esteem) after the successful results of weight loss surgery, these results should not be the overriding motivation for having the procedure.

Deciding to undergo a bariatric surgical procedure will change your life in a dramatic and permanent way – and there is no such thing as too much careful consideration. Even if you are interested in having surgery, your goals should be to live better, healthier and longer.

For these reasons, you should make the decision to have weight loss surgery only after careful consideration and consultation with an experienced bariatric surgeon or a knowledgeable family physician. A qualified surgeon should answer your questions clearly and explain the exact details of the procedure, the extent of the recovery period and the reality of the follow-up care that will be required. They may, as part of routine evaluation for weight loss surgery, require that you consult with a dietician/nutritionist and a psychiatrist/therapist. This is to help establish a clear understanding of the post-operative changes in behavior that are essential for long-term success.

It is important to remember that there are no ironclad guarantees in any kind of medicine or surgery. There can be unexpected outcomes in even the simplest procedures. What can be said, however, is that weight loss surgery will only succeed when the patient makes a lifelong commitment. Some of the challenges facing a person after weight loss surgery can be unexpected. Lifestyle changes can strain relationships within families and between married couples. To help patients achieve their goals and deal with the changes surgery and weight loss can bring, most bariatric surgeons offer follow-up care that includes support groups, dieticians and other forms of continuing education.

Ultimately, the decision to have the procedure is up to you. After having heard all the information, you must decide if the benefits outweigh the side effects and potential complications. This surgery is only a tool. Your ultimate success depends on strict adherence to the recommended dietary, exercise and lifestyle changes.

Some of the following are considerations that go into the decision making process - whether surgery is offered as an option, and whether you choose the surgical option.

• Weight: Surgery is only offered when a patient is so heavy that they meet the medical definition of morbid obesity and have failed dietary and medical management of this problem. For patients who do not meet this criteria, the risk of surgery outweighs the expected health benefits of the weight loss. Bariatric surgery should not be done for only cosmetic reasons. Unlike other centers in the country, we currently do not offer bariatric surgery to someone who does not meet the weight criteria.

• Ability to comply with therapy: You must be able to follow the advice of your surgeon, especially regarding dietary habits after surgery. Bariatric surgery is only a tool - it is unrealistic expectation if a patient depends only on the procedure to "take care of the weight problem" in some magical way. Dietary habits that we recommend after a gastric bypass are simple and very effective if adhered to. As you explore this site, you will learn that bariatric surgery is a powerful tool to achieve long-lasting weight loss if used correctly.

• Complicated medical conditions: Some people who are severely obese are extremely ill as a result of their obesity. In these individuals, the excess weight has caused significant and permanent damage to one or more organ systems. The most commonly affected organs are the lungs (sleep apnea), the heart (congestive failure or coronary artery disease), the kidneys (damage from diabetes or high blood pressure), and bones and joints (damage from stress and arthritis). Medical problems like these increase the risk of any major surgical procedure including bariatric surgery, but they also strengthen the need for weight loss. In other words, patients with these medical conditions require careful consideration, but do not necessarily contraindicate surgery. It is the sole decision of our surgeons at UIHC to decide whether your risk of undergoing surgery outweighs your current medical risks – and then offer you gastric bypass surgery.

• Age: Surgical candidates at the extremes of the age spectrum also require extra consideration to evaluate the appropriateness of surgery. At UIHC, we generally do not offer this kind of surgery to patients who are older than their 60 years of age or younger than 20 years since they may be at a higher-than-average risk for this operation and also because they may not completely benefit from its outcome. For example, older patients may not be physically active and will therefore not be able to comply with the exercise regimen after surgery. Similarly, on the younger side of the age spectrum, the concern is not medical risk but more a question of whether the individual can really understand what they are getting into. Patients must demonstrate exceptional maturity and independent thought to be good candidates for a bariatric surgical procedure.

Paying for Weight Loss Surgery

• Will my health insurance pay for the procedure?
• The Appeals Process

At some point, after you have spent time exploring the option of weight loss surgery, you will need to determine how to pay for the procedure.

Will my health insurance pay for the procedure?

Although most insurance companies in Iowa pay for bariatric surgery if the need is documented by the surgeon, many of them require the following:

• Being double ideal body weight.
• Documentation of 5 years history of severe obesity.
• Documentation of 12-24 months of professionally supervised weight loss programs with six months being in the last year.

Please check with your health care plan to determine whether you meet their criteria. If you  do not have insurance and are interested in participating in our self pay program, please call 319-356-1887 for information.

A growing number of states have passed legislation requiring insurance companies to provide benefits for weight loss surgery for patients that meet the National Institutes of Health surgical criteria. While insurance coverage for weight loss surgery is widespread, it often requires a lengthy and complicated approval process. The best chance for obtaining approval for insurance coverage comes from working together with your surgeon and other experts.

Here are some of the key steps you should take to obtain insurance coverage for weight loss surgery:

• Read and understand the "certificate of coverage" that your insurance company is required by law to give you. If you do not have one, consult your company's benefits administrator or ask your insurance company directly.

• You may be required to start with your primary care physician. In some cases, he or she is the only one you can ask for a referral to a qualified bariatric surgeon. Even if you are not required to get a referral, it is a good idea to have the support of your primary care physician.

• Before visiting the bariatric surgeon, organize your medical records, including your history of dieting efforts. They will be valuable documents to have at every stage of the approval process.

• Document every visit you make to a healthcare professional for obesity-related issues or visits to supervised weight loss programs. Document "other" weight loss attempts made through diet centers and fitness club memberships. Keep good records, including receipts.

• If your surgeon recommends weight loss surgery, he or she will prepare a letter to obtain pre-authorization from your insurance company. The goal of this letter is to establish the "medical necessity" of weight loss surgery and gain approval for the procedure. The following information is generally included in the pre-authorization letter:

• Your height, weight and Body Mass Index and any documentation you might have as to how long you have been overweight.

• Simply describing your condition as "morbid obesity" is not enough. A full description of all your obesity-related health conditions, including records of treatment, a history of medications taken and documentation of the effects these conditions have had on your everyday life is necessary.

• A detailed description of the limitations your excess weight places on your daily activities, such as walking, tying shoes, or maintaining personal hygiene.

• A detailed history of the results of your dieting efforts, including medically and non-medically supervised programs, medical records and records kept of payments to and meetings attended with commercial weight loss programs.

• A history of exercise programs, including receipts for memberships in health clubs.

• Ask your doctor to include information from medical journals regarding the effectiveness of weight loss surgery, particularly information showing the control or elimination of obesity-related health conditions.

Thirty days is the standard time for an insurance provider to respond to your request. You should initiate a follow-up if you have not heard from your insurance company in that time.

Most insurance companies recognize the health consequences of obesity and cover the costs of the surgical management of weight loss in qualifying patients. However, every insurance plan is different.

Because of this, we coordinate patients' insurance applications. Once the physician has recommended surgery, we start the process to seek insurance authorization. We begin by sending a letter to the patient's insurance company requesting coverage for the surgery. It usually takes about  four to six weeks for the insurance company to approve the application.

We will call the patient once we receive word from the insurance company of approval or denial. If the coverage is approved, a surgery date and pre-op appointment is scheduled for the patient. If coverage is denied, we resubmit the application and go through the appeal process with the insurance company.

The Appeals Process

Even if your initial request for pre-authorization is not approved, you still have options available. Insurers provide an appeal process that allows you to address each specific reason they have given for denying your request. It is important that you reply quickly. It is also recommended that, at this point, you enlist the help of an experienced insurance attorney or insurance advocate to properly navigate the complexities of the appeal process. Some insurers place limits on the number of appeals you may make, so it is important to be well prepared and that you clearly understand the appeal rules of your specific plan.