General Surgery

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 What medical criteria need to be met to be a candidate for weight loss surgery?

According to the National Institutes of Health the following medical criteria need to be met to be considered a candidate for weight loss surgery:

  • A person must be a minimum of 100 pounds overweight or has a Body Mass Index (BMI) greater than 40.  -OR-
  • A person with a BMI of 35 with serious health problems caused by being overweight (sleep apnea, high blood pressure, or diabetes).  -AND-
  • A person who has tried medically supervised dieting to try to lose weight, but has been unsuccessful at keeping it off.  -AND-
  • A weight loss surgeon determines you are at low risk for obesity surgery.
 What questions should I ask my insurance company when I call to see if weight loss surgery is a covered benefit?
  • Do I have benefits available for gastric bypass, sleeve gastrectomy or lap band surgery? 
  • Do I need a referral to see the doctor, for any of the tests he may order, or for surgery?
  • Will I be responsible for any portion of the cost of the surgery, office visits, and/or tests?  (deductibles, co-pays, co-insurance costs)
  • Is there a financial cap/limit for weight loss surgery?
  • Is Froedtert Hospital and its bariatric surgeons (James Wallace, Matthew Goldblatt, Jon Gould) in-network for my plan?
  • Are there specific criteria that I have to meet before getting authorization for my surgery?  (examples-physician supervised weight loss, weight history, letter of support from my primary care physician)
  • Will my follow-up visits and lab work be covered?
  • If I have a lap band placed, will my future adjustments be covered?  Will these visits need prior authorization?
 What type of additional criteria might my insurance company require?
  • Many insurance companies now require three or six consecutive monthly visits for physician supervised weight loss.
  • These visits must be documented in your doctor’s office chart and these clinic notes will need to be submitted to your insurance company by our office if required.  A summary letter is not sufficient documentation.
  • Many insurance companies are requesting a letter of support from your primary care physician.
  • Many insurance companies are requesting a 5-year weight history to confirm that you’ve been battling the disease of morbid obesity for a period of time.
 Which operation(s) are done at Froedtert and the Medical College of Wisconsin?
  • Laparoscopic roux en y gastric bypass
  • Open roux en y gastric bypass
  • Laparoscopic sleeve gastrectomy
  • Laparoscopic Adjustable Gastric Band (commonly referred to as LapBand)
 What testing will I need to have done before my surgery?
  • A TSH blood test which measures how well your thyroid is working.
  • A psychological evaluation.
  • Individual consultation with our bariatric dietitian.
  • Physician supervised weight loss (if required by your insurance company).
  • Sometimes patients will need a sleep study, special heart testing or breathing tests.  This will be determined by the surgeon at the time of your visit.
 When is my paperwork sent to my insurance company?

When you have completed all of the required appointments and we have received all of the necessary test results and written materials required by your insurance company.  Our office calls you when your papers are sent to your insurance company.

 How long will it be before my surgery is scheduled?

Surgery is scheduled when we receive approval from your insurance company.  This length of time varies between insurance companies.  In general, most insurance companies require 30 business days to complete a medical review and make a determination.

 What are the qualifications of your surgeons?
  • Our surgeons are certified by the American Board of Surgery and are members of the American Society for Bariatric Surgery.
  • Froedtert Memorial Lutheran Hospital and The Medical College of Wisconsin’s Bariatric Surgery Program and James R. Wallace, MD, PhD, Jon C. Gould, MD and Matthew I. Goldblatt, MD have been designated a “Center of Excellence for Bariatric Surgery” by the American Society for Bariatric Surgery.
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Page Updated 08/05/2014