Medical Necessity:

Very simply, medical necessity is the basis for weight loss surgery. Medical necessity is actually a legal term, but its implications are very broad. Every weight loss surgery procedure should be performed for the sole purpose of improving or curing obesity related diseases and not for cosmetic purposes. Medical necessity is used by surgeons and insurance companies to evaluate the candidacy of a prospective bariatric surgery patient. The criteria for medical necessity are met when obesity becomes a significant threat to the prospective patient’s health or life.

Obesity is a disease in and of itself, and it spawns other diseases called comorbidities. These diseases can lead to serious and even life-threatening conditions. Obesity-related diseases include type II diabetes, high cholesterol, high blood pressure and sleep apnea. The results of these comorbidities are severe and can include chronic problems such as cardiovascular disease (heart attack and stroke), joint disorders, some forms of cancer and psychological problems.

Many insurance companies will use medical necessity as a litmus test, basing their approval of coverage on whether they believe the obese person’s health or life is in jeopardy. As a result of the lack of clarity on the definition of medical necessity, every insurance company will likely have a different opinion on what it actually means. Patients can get a good idea of what to expect by calling their insurance company when they decide to undergo bariatric surgery. Finding out qualifications for surgery will give the patient clarity on what they need to prove before receiving coverage.

The decision to undergo bariatric surgery should not be taken lightly. It is not a cosmetic procedure and should be a last resort when no other methods of weight loss can control the obesity and the diseases associated with it.

Insurance companies may require a medical necessity form.