When Gastric Sleeve is Medically Necessary

Dec 21, 2017 admin blog 0 comments

Approximately one-third of American adults are considered obese. While bariatric surgery can be a lifeline for individuals who have been unable to lose their excess weight through conservative means, it is not appropriate for all patients. Since gastric sleeve and other bariatric surgeries involve significant and typically permanent changes to the digestive system, bariatric surgeons use the concept of medical necessity to determine if an individual is a suitable candidate for the procedure.

When Is Bariatric Surgery Medically Necessary?

Because weight loss surgery is not intended to be an initial treatment for obesity, most surgeons and insurance companies follow the guidelines set forth by the National Institutes of Health in determining if gastric sleeve or other bariatric surgery is medically necessary. Bariatric surgery may be an option for individuals who:

  • have a body mass index of at least 40, or
  • have a body mass index of at least 35 along with an obesity-related health condition, such as heart disease, sleep apnea, or diabetes.

Teenage patients who have gone through puberty and reached adult height may meet medical necessity guidelines if they meet the following criteria:

  • a body mass index of at least 35 along with a serious obesity-related health condition, such as diabetes, or
  • a body mass index of at least 40 with high blood pressure, high cholesterol, or another less severe obesity-related health problem.

In addition to the medical necessity requirement, patients normally have to show that they have made a serious attempt to lose the weight through non-surgical means, such as a medically supervised diet. The American Heart Association recommends that patients participate in a supervised weight loss program for at least 6 months before considering bariatric surgery.

Making the Commitment

Patients undergoing bariatric surgery should think of the process as a marathon rather than a sprint. Patients must understand that their eating and physical activity patterns will change following the surgery. To ensure the best possible results and prevent complications, patients must follow specific diet and exercise guidelines for the rest of their lives and follow-up with their doctor on a regular basis.

The payoff, however, is significant. By working toward and maintaining a healthy weight, patients have the potential to reduce their risk of cardiovascular disease, diabetes, high blood pressure, and even certain types of cancer. Patients considering bariatric surgery should consult with a bariatric surgeon to ensure that they understand and meet all of the requirements for medical necessity.

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