2 Ways to Meet the Gastric Sleeve Surgery Requirements

Medically Reviewed by:  

John Rabkin, MD, FACSBoard Certified Bariatric Surgeon

Last Updated:  

11/27/2020

The minimum requirements to qualify for gastric sleeve surgery include:

• A body mass index (BMI) of 40 or more, OR
• A BMI between 30 and 39.9 with a serious obesity-related health problem like diabetes, high blood pressure, sleep apnea, high cholesterol, joint problems, and many others

However, protocols are a bit more stringent if you want insurance to pay, such as requiring a 35+ BMI and a completed medically supervised weight loss program.

Patients who qualify for gastric sleeve surgery usually:

• Are at least 80 lbs (36 kg) overweight
• Are between 18 and 75 years old
• Have a history of failed weight loss attempts (example: failed diets)
• Thoroughly understand that the procedure is just a tool; your long-term success requires you to make significant diet and lifestyle changes

Read the sections below to learn everything you need to know about qualifying for gastric sleeve surgery.

Click here to calculate how much weight you'll lose in the first year

Before and after weight loss success

Individual results may vary

TABLE OF CONTENTS

Click on any of the topics below to jump directly to that section

1. Insurance Approval
2. Reasons for Disqualification
3. Next Steps If You Qualify
4. Options If You Do Not Qualify
5. Find a Gastric Sleeve Surgeon

Advertisement

How to Get Insurance Approval for Gastric Sleeve Surgery

First, find out if gastric sleeve is included under your policy by (1) using the tool below or (2) clicking here to access the weight loss surgeon directory. Most surgeons will check your insurance for free to confirm coverage criteria.

If gastric sleeve insurance coverage is included under your policy, you will need to meet all of your insurance company’s coverage criteria (click here for list of insurance companies) to confirm the “medical necessity” of your surgery.

Assuming you follow all the guidelines and provide complete, accurate information requested by your insurance company, the gastric sleeve insurance approval process from start to finish can take anywhere from one month to one year.

Here is how to get insurance to pay for gastric sleeve:

1. Minimum body mass index (BMI) requirements to be confirmed by your physician:
   • BMI over 40 –OR–
   • BMI from 35 and 39.9 with one or more of the following:
     • Clinically significant obstructive sleep apnea
     • Coronary heart disease
     • Medically refractory hypertension
     • Type 2 diabetes mellitus
   • BMI from 30 to 34.9 – may be approved on a case-by-case basis
2. Complete a medically supervised diet program (3 to 7 consecutive months, depending on insurance company).
3. Schedule a consultation with your bariatric surgeon (your surgeon can coordinate your medically supervised diet program as well).
4. Schedule a consultation with your primary care physician to obtain a medical clearance letter.
5. Schedule a psychiatric evaluation to obtain a mental health clearance letter.
6. Schedule a nutritional evaluation from a Registered Dietitian.
7. Send all of the above documentation to your insurance company along with a detailed history of your obesity-related health problems, difficulties and treatment attempts. The review process typically happens in under one month.
8. Insurance company sends approval or denial letter:
   • If approved, your surgeon’s bariatric coordinator will contact you for scheduling.
   • If denied, you can choose to appeal the denial.

We highly recommend contacting a surgeon to do all of the legwork for you and to help you through the process. They are very experienced in managing each stage of the process, and may have all of the required personnel on staff (e.g. registered dietitian, psychiatrist, bariatric coordinator, etc.).

Click here to access the weight loss surgeon directory to get started.

Reasons You Won’t Qualify for Gastric Sleeve

Characteristics that may disqualify you from having gastric sleeve surgery include:

• Low body mass index (not being heavy enough) – see BMI requirements at the top of this page
• Under 18 years old (although patients as young as 14 may be approved under certain circumstances)
• Limited past diet attempts
• Current pregnancy (or anticipated pregnancy within 2 years) – click here and here for surgeon Q & A about getting pregnant after having the gastric sleeve procedure
• Current infection
• Having very high operative risks, such as a patients with a severe heart or lung disease
• Substance abuse
• Major mental health issues that may prevent firm understanding of surgery and required lifestyle changes
• inflammatory disease or condition of the gastrointestinal tract, such as ulcers, severe esophagitis, Barrett’s esophagus, or Crohn’s disease
• Portal hypertension
• Abnormal esophagus, stomach, or intestine
• Cirrhosis
• Chronic pancreatitis
• On chronic, long-term steroid treatment
• Not willing to follow long-term diet, vitamin, or exercise regimen
• Autoimmune connective tissue disease
• Uncontrolled or untreated psychiatric disorder
• Suicide attempt in last 18 months or multiple attempts within last 5 years

Conditions that may or may not disqualify you include:

• Severe GERD

If you have any of the above issues, contact a weight loss surgeon to discuss your options.

For a list of frequently asked questions about qualifiers (and disqualifiers), see our page “Do I Qualify For Weight Loss Surgery?”

Advertisement

Next Steps if You Meet the Requirements for Gastric Sleeve Surgery

If you have insurance, click here to review the section above for next steps.

If you do not have insurance, the next step is to determine how you will pay for surgery. Options include:

• Private insurance
• Medicare or Medicaid
• Payment plan through surgeon
• Secured medical loan
• Unsecured medical loan
• Retirement plan loan
• Life insurance policy loan
• Loan from family or friends

See our Financing Weight Loss Surgery page for more information.

Your Options if You Do Not Meet the Requirements for Gastric Sleeve Surgery

If you do not meet the minimum gastric sleeve qualification requirements, you may still qualify for the gastric balloon procedure.

The gastric balloon procedure (endoscopic intragastric balloon) leaves an inflated silicon balloon(s) in the stomach for 6 months, making less room for food. As a result, patients:

• Feel full sooner while eating and therefore eat less
• Lose about 30% of their excess weight in 6 months
• Have health improvement for diabetes, joint/bone disease, and heart-related issues

  You could be a good candidate for the gastric balloon procedure if you:

• Are at least 18 years of age
• Have a body mass index (BMI) in the following ranges by country:
  • United States: between 30 and 40
  • Canada: above 27
  • Australia: above 27
  • Mexico: above 27
  • United Kingdom: above 27
• For some types of balloons, such as the ReShape Balloon, you must have a health risk associated with obesity (also known as a “comorbidity”) like diabetes, high blood pressure or sleep apnea. For other balloon types, like the Orbera balloon, no comorbidities are required.

See our Gastric Balloon Patient Guide for more information.

Find a Gastric Sleeve Surgeon