When we look back on our lives each of us can identify certain major milestones. Some were the result of events that we couldn’t control. Others were things that we specifically caused to happen by virtue of our own actions. Making major decisions of this nature takes courage, whether they be buying a home, changing jobs, or deciding to do something definitive about chronic obesity.
Every patient I see has a different story to tell about how they came to their decision to get an a Adjustable Gastric Band. However, what is common to each story is an underlying awareness that they’ve tried everything and nothing seems to work. Ultimately, the majority of my patients tell me that their decision was in fact one of those life-altering milestones.
Coming to a Crossroads Treating Obesity as a Disease
For many people the decision to have weight loss surgery to help them lose weight comes only after extensive research. For others it may be the result of having personally observed the success of a close friend or family member. Regardless of what triggers that decision, it makes sense only if you have come to the realization that you aren’t able get control over your weight by yourself. This is tough, because we invariably feel like a failure whenever we have to admit we can’t do something on our own.
Prospective patients frequently start out trying to explain to me all the reasons why they haven’t been successful losing weight on their own. Before they get too far into their list I stop them and ask, “Do you think you could treat your own heart attack?” Obesity is a disease, and like any other disease it requires professional treatment. Once you learn to view it as such and recognize that being involved in a weight-management program is in fact a medical treatment designed to control that disease, your success will come much easier. The true crossroads isn’t the decision to get a band; it’s the decision to change the way you look at your obesity.
The Minimum Criteria – Who is a Adjustable Gastric Band suitable for?
While your actual weight in pounds and your specific EMI are important, I think it is of greater importance to look at individuals and how their weight affects their health, both now and in the future. But everyone is obsessed with numbers, so what follows are “the numbers.”
Back in post How Do I Know if Weight Loss Surgery is right for Me? we talked about Body Mass Index (BMI) and how it is used to create the categories of obesity. A EMI of 25 to 30 kg/m2 is classified as “overweight.” A BMI of 30 to 40 kg/m2 is classified as “obese.” A EMI above 40 kg/m2 is classified as “morbidly obese,” and one over 80 kg/m2 falls into the “super obese” category. Anyone can calculate their own BMI using the formula BMI = body weight in kilograms divided by height in meters squared. Generally it is easier to determine your BMI using a chart like this one:
Most surgeons agree that patients should meet some minimum criteria before even considering bariatric surgery. This is not something that should be done for someone who needs to lose just 20 or 30 pounds. A number of years ago, the American Society of Bariatric Surgeons (ASBS) developed some general guidelines for its members to use when evaluating patients for weight-loss surgery. Under those guidelines, for a patient to be considered for any type of bariatric surgery, including the Adjustable Gastric Band, they should have a BMI greater than 40 kg/m2, or a EMI greater than 35 kg/m2with at least one significant medical comorbidity, such as Type 2 diabetes, hypertension,
sleep apnea, major arthritic changes, or gastroesophageal reflux disease. The patient’s obesity should also be a chronic problem, generally of five years’ duration or longer, and during that time the patient should have made a reasonable effort to lose weight through dieting and exercise.
Checklist: General Criteria for Weight-loss Surgery Patients
(Established by the American Society of Bariatric Surgeons)
- BMI greater than 40 without a medical co-morbidity.
- BML greater than 35 with a medical co-morbidity.
- Obesity chronic for five years or longer.
- Reasonable efforts made to lose weight through dieting and exercise.
Clearly, insurance coverage is a huge issue for most prospective patients. But the fact is that each and every policy is different, creating an extraordinarily challenging set of problems. However, virtually all policies that offer coverage for bariatric surgery have adopted the Standards for Bariatric Surgery guidelines at DHA as criteria, which must be met before the patient can be approved for any weight-loss procedure. These guidelines were never meant as absolute rules for performing bariatric surgery, but, with the dramatic increase in demand, the insurance industry has elected to adopt them as rigid criteria for paying weight-loss surgery claims.
That can be a major source of conflict, because the “criteria” are not always followed in determining whether a claim is paid. And, as I eluded to, many policies have specific language in them that excludes coverage for any bariatric surgery. It is also important to realize that insurance coverage for bariatric surgery, and the Adjustable Gastric Band in particular, can be added to the list of excluded procedures by the insurer without notification at the annual renewal of the policy. Such exclusions for bariatric surgery take effect immediately, so just because a policy covered the band operation one year, doesn’t mean it will cover it the next.
While it is relatively easy to measure your BMI, the presence of comorbidities can be and often is disputed by insurance companies. Despite the presence of “written criteria,” arguments frequently arise when attempting to define the “medical necessity” for bariatric surgery.
Even after getting letters from physicians and documenting medical conditions, many patients are also required to document their weight-loss efforts. As you might expect, those efforts are then subject to interpretation. Some policies require that specific dieting efforts be under the direct guidance and supervision of a physician, but even then the level of supervision can come into question.
When patients find out that their insurance doesn’t cover the cost of bariatric surgery, or the band in particular, the most common response I hear is, “Don’t they understand that I am going to cost them less in the future when I no longer need medications for diabetes and high blood pressure?” While this sounds like a reasonable argument, the fact is that insurance companies are not in the business of investing in your future health. The economic benefits of weight loss are obvious, but they are realized over a number of years. The insurance company has no assurance that you will remain insured by them beyond the current contract year, so they have little incentive to provide coverage based on future savings.
Another insurance issue is somewhat unique to the Adjustable Gastric Band. Following the procedure, the band must be adjusted, often several times over a period of months. These adjustments are not part of the procedure, and therefore the insurer may not pay for adjustments even if the operation was covered. Likewise, most policies don’t even recognize a comprehensive weightmanagement program, but instead place all of the emphases on the surgery. This inappropriately discounts the other elements critical to the patient’s success.
Without question, insurance coverage makes it possible for some people to access healthcare who might not otherwise have the means to pay for it. But at the same time there are many others who are denied bariatric care through this system. The system has evolved to the point where many, if not most, people perceive that healthcare is available only through their insurance. Therefore, if they are denied coverage for obesity surgery they feel they have no other choice. To address this problem, many surgical practices offer a number of financing options for those without insurance coverage. That allows patients to choose for themselves how they wish to deal with this lifelong condition.