Do You Qualify for Bariatric Surgery?

It seems a straightforward question, but it turns out there are two slightly different answers, depending on who you ask.

For most patients, the important answer is the one they get when they ask their health insurance company. Health insurers usually adhere to the selection criteria set down in 1991 in the National Institutes of Health’s Consensus Development Conference Statement, and if you want your insurance to cover your surgery, you will likely have to meet those criteria.

The NIH statement says that surgery is appropriate for motivated, obese adults who have earnestly attempted dieting. It stipulates that patients whose Body Mass Index exceeds 40 are potential candidates for surgery. The NIH adds, however, that patients with a BMI between 35 and 40 can become candidates if they have specific medical conditions such as hypertension, obstructive sleep apnea, type II diabetes mellitus, certain kinds of heart disease, or a disabling joint disease related to excess weight.

The NIH statement is now more than 20 years old, and quite a bit has changed in that time. For one thing, bariatric surgery is much safer than it used to be. That statement was written before the age of minimally-invasive surgery. There was no LAP-BAND or sleeve gastrectomy in 1991, and if you wanted a gastric bypass, it was going to be the kind with a big, open incision. It is not an exaggeration to say that gastric bypass surgery is now more than twenty times safer than it was in 1991 when these rules were adopted.

The other thing that has changed is our understanding of how effective bariatric surgery is at resolving important medical problems. For many patients with type II diabetes, it is the only cure – the only chance of escaping progression of the disease.

These two factors - increased safety and increased awareness of its health effects - have caused the medical community to re-evaluate the cutoffs for bariatric surgery. A recent study performed at the Cleveland Clinic showed that diabetic patients with a BMI as low as 27 can benefit from bariatric surgery. Although bariatric surgery on patients with BMIs in the 20s is still controversial, surgery is considered quite acceptable now for patients with a BMI over 30 – at least in the setting of diabetes.

Even though patients in this intermediate zone are sometimes appropriate candidates for surgery, those who seek it are usually left to cover the cost themselves. The medical community is working on this problem, and attitudes are slowly changing.