The most important questions about bariatric surgery programs offered by your #1 team at Surgical Healing Arts, SW Florida
All insurances cover bariatric surgery, but employers are able to choose whether to include bariatric coverage in the contract they negotiate with the insurance company. If an insurance policy has a “Bariatric Exclusion,” insurance will not cover the procedure even if medically necessary or recommended by a doctor. Call your insurance company and ask if bariatric surgery is a covered benefit. Coverage, benefits and insurance criteria will also be checked by our office staff prior to your visit if you provide your insurance information when scheduling your first appointment. Bariatric surgery is a covered benefit under Florida Medicaid, Medicare and Medicare replacement plans.
Insurance eligibility is based on both body mass index (BMI) and obesity related illnesses (comorbidities). The lower cutoff for BMI is 35. Typically, a patient with BMI between 35 and 40 must also have an obesity related illness such as high blood pressure, diabetes, fatty liver disease, sleep apnea or severe osteoarthritis. Patients with a BMI over 40 are typically eligible without an obesity related illness with private insurance, but Medicare and Medicaid always require an obesity related illness regardless of the body mass index.
BMI stands for Body Mass Index. BMI is a way of calculating and comparing the degree someone is over or under average weight. The formula uses height and weight to calculate a number that is used in research studies to help define what levels of obesity are related to various diseases and estimate risk of illness based on degree of obesity.
Levels of obesity based on BMI are as follows:
- Normal Weight: 18-25
- Overweight: 26-30
- Obese: 31-35
- Morbidly Obese: 36-40+ (Morbid obesity refers to a level of obesity that is more likely to be related to illnesses such as high blood pressure, diabetes, sleep apnea, fatty liver disease, some cancers, etc.)
Bariatric surgery has been done for more than 30 years. Techniques have evolved and refined, and procedures have changed in many ways. Through many research studies and collaboration between surgeons, medical doctors, instrument companies and other healthcare specialists, the safety of bariatric surgery is now equal to gall bladder removal or knee replacement surgery. Though there are risks to any surgery, the benefits of bariatric surgery far outweigh the risks and have been shown to add an average of nine years to life expectancy. Many precautions and preparations are taken prior to bariatric surgery to minimize as much risk as possible.
Bariatric surgery has been shown to improve and resolve high blood pressure, diabetes, high cholesterol and triglycerides, sleep apnea and fatty liver disease, as well as a decrease in the chance of contracting some cancers. Improvement in many of the illnesses occurs at the time of surgery even before much weight is lost and continues as weight comes down. Obesity related illnesses will generally stay resolved as long as the patient does not regain the weight, but will return if weight increases again, regardless of whether the patient has had surgery.
Research studies describe the rate of weight regain after bariatric surgery as 20 percent, which is drastically improved over the 95 percent chance of weight regain after non-surgical weight loss. Bariatric surgery is a tool, and only a tool — and must be used as a tool, not a fix. Bariatric surgical patients must follow lifetime guidelines to assure they are getting appropriate nutrition and hydration, and use appropriate exercise for their ability to avoid weight regain. Bariatric patients do not need to be perfect in their patterns, but they do need to be consistent — for life. A bariatric surgical patient will never be able to go back to the types and volumes of food consumed before surgery. Weight regain is dependent upon the awareness and commitment to lifetime pattern changes of each bariatric patient, but bariatric patients will attest to the fact that the surgery gives them the help they need to be able to maintain the healthy patterns the surgery requires.
Patients whose insurance does not cover bariatric surgery or patients without insurance often resort to paying for their surgery “out of pocket.” The current cost for the sleeve gastrectomy, the most common bariatric surgical procedure is $12,500. The fee includes anesthesia, hospital costs for the surgery and overnight stay, surgeon fee, a bariatric program fee that includes pre-op education and post-op support, and a year of follow-up visits. The self-pay fee does not include preoperative medical workup such as labs, chest X-ray and medical clearances. But even when insurance will not cover surgery, it will cover pre-surgical workup as those items are billed under non-surgical codes. Patients who require hiatal hernia repair are eligible for a reduced self-pay rate as insurance will pay for hiatal hernia repair, bringing the self-pay price for sleeve gastrectomy to $10,000.
Support after surgery is very important in your success. An ongoing relationship with your surgeon and regular follow-up will help you maximize your patterns for the best weight-loss possible. In addition to regular medical follow-up visits, patients are encouraged to attend a monthly support group. Support group topics vary, but no matter what the topic, there is great value in meeting and talking with other patients who are living the same bariatric life. In addition to support groups, monthly walks in local parks, intermittent special events such as 5K run/walks and twice monthly “Living With It” classes are available to support you on your journey to a healthier weight. If further emotional support is needed, referral to counseling professionals can be arranged.
There are many tasks that must be completed prior to bariatric surgery. The tasks revolve around the insurance requirements, educational needs and medical clearances necessary to get you to and through surgery safely. Insurance requirements vary, but generally include a few months of medically supervised weight management, psychological clearance, and a history of what previous attempts at weight-loss have been made. Education will be provided to fully prepare you not only for the surgery and recovery, but for living with bariatric surgery for life. Medical clearance items are designated based on each patient’s medical problems and history, but typically include chest X-ray, blood laboratory studies, EKG and clearance from a cardiologist. Typically, it takes three to four months to complete all required items.
The hospital stay for sleeve gastrectomy is overnight and two to three days for gastric bypass. Recovery is dependent on each individual, but generally patients who are employed are ready to go back to work in two weeks after sleeve gastrectomy and three weeks after bypass surgery. After surgery, diet slowly progresses from liquid to regular over the period of one month. Patients typically feel fatigue that steadily improves over the following eight to 12 weeks after surgery. As patients lose weight, they continue to feel better and become more healthy as their illnesses, like diabetes and high blood pressure, resolve.
Diet after surgery progresses from thin liquids, to thicker liquids, to mushy foods to regular diet over the period of one month. After one month, a bariatric diet consists of mostly protein foods with some fruits and vegetables. During the weight-loss phase, carbohydrate foods are avoided as they will stop weight loss. After desired weight loss has been achieved, healthy carbohydrates may be added in small volumes, but bariatric patients must always put protein as the main focus.
Bariatric patterns of eating focus on eating small volumes of predominantly protein foods frequently to allow consumption of a total protein goal of 70-90 grams of protein per day. Carbonated beverages are avoided for life after bariatric surgery as they can stretch the surgically created stomach pouch. Additionally, all beverages consumed must be non-caloric as liquid calories contribute to weight regain.
Bariatric patients try to consume between 70-90 grams of protein per day to maintain lean muscle mass and keep the metabolism burning fat. That amount is not considered a “high protein” diet, but, because of the small stomach volume, special attention must be paid to food choices to assure the protein goals are met in as low a calorie range as possible.
Most bariatric patients do not find eating out difficult after surgery as protein is generally a part of most entrees available at restaurants. Many patients enjoy their food more after surgery because they focus on flavorful protein-based foods they enjoy, instead of “diet” foods that lack flavor and are unfulfilling. Favorite protein-based foods are easily modified to support healthy bariatric eating.
Bariatric patients can experience “Dumping Syndrome” also known as “Reactive Hypoglycemia” in response to high-sugar and/or high-fat foods. Dumping Syndrome can include palpitations, sweating, abdominal cramping, extreme fatigue, vomiting or diarrhea. Dumping syndrome is much more pronounced in gastric bypass, but some more mild symptoms have been noted in sleeve gastrectomy as well. Dumping can be completely avoided by avoiding the foods that trigger the symptoms.
Yes, vitamin supplementation is required for life after bariatric surgery. Research has shown that protein and multiple vitamin deficiencies will develop in patients at about two to three years post-surgery in both sleeve and gastric bypass. Deficiencies are related to both the small volume and narrow range of food consumed after bariatric surgery. The most common deficiencies are iron, Vitamin B12, Vitamin D, Vitamin B1, Zinc, Calcium and protein. The amounts of vitamins and nutrients found in regular over-the-counter vitamins are not sufficient for bariatric patients.
Bariatric surgery is a tool to assist in weight loss and management. Consistent patterns of healthy food choices and exercise are important not only for initial weight loss, but for maintenance of weight loss. Weight regain happens in 20 percent of bariatric surgery patients. Weight regain occurs when patients lose awareness and consistency in their patterns of healthy eating and exercise. In some cases, long-term complications can happen that make eating healthy protein foods difficult, causing patients to gravitate to carbohydrate foods that are easier to tolerate. Frequently, these patients will gain weight due to the high carbohydrate diet. Overall, 80 percent of bariatric patients will lose and maintain their weight.
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