Most people are surprised to learn that they qualify for weight-loss surgery. The criteria are broader than they were even a few years ago, and insurance coverage has followed. Below is a plain-language guide to the requirements we see most often in Virginia.
BMI thresholds
The traditional National Institutes of Health criteria, still used by almost every insurer, are:
- BMI 40 or higher — surgery is generally covered on the basis of weight alone.
- BMI 35 to 39.9 — surgery is covered when you also have at least one obesity-related medical condition (see below).
- BMI 30 to 34.9 — the American Society for Metabolic and Bariatric Surgery (ASMBS) now supports surgery at this range when type 2 diabetes is present. Coverage varies by plan.
Obesity-related medical conditions
If your BMI is 35 to 39.9, any of the following conditions typically satisfies the second requirement:
- Type 2 diabetes or prediabetes
- High blood pressure (hypertension)
- High cholesterol or triglycerides
- Obstructive sleep apnea
- Fatty liver disease (NAFLD or NASH)
- Severe joint disease, especially of the knees or hips
- Gastroesophageal reflux disease (GERD)
- Polycystic ovary syndrome (PCOS) or infertility related to obesity
- Asthma made worse by weight
Insurance-supervised diet requirements
Many commercial insurers in Virginia — including several Anthem Blue Cross Blue Shield of Virginia and Aetna plans — require a documented physician-supervised weight-loss program before they approve surgery. The program is usually three to six consecutive monthly visits with a physician or dietitian, with recorded weights, dietary counseling, and an exercise plan. Medicare and Medicaid in Virginia no longer require a supervised diet.
Our office handles the paperwork and coordinates the supervised-diet visits when your plan requires them. See our insurance coverage guide for specifics.
Age
Most bariatric programs treat adults from about 18 through 70. Age alone is rarely a barrier — a healthy 72-year-old is usually a better candidate than an unwell 45-year-old — and Medicare covers bariatric surgery for qualifying patients regardless of age. Adolescent surgery is offered through specialized pediatric programs and is not part of our practice.
Other requirements you may encounter
- A psychological evaluation to confirm readiness and screen for untreated eating disorders.
- A nutrition evaluation with a registered dietitian.
- Basic labs, an EKG, and — for some patients — a sleep study or cardiology clearance.
- A commitment to lifelong vitamin supplementation and follow-up visits.
The bottom line
If your BMI is 35 or higher — or 30 or higher with type 2 diabetes — you probably qualify. The fastest way to find out for sure is a free consultation. We will review your BMI, medical history, and insurance plan in one visit and tell you exactly what your path to surgery looks like.