Bariatric Surgery Eligibility Checker

What this tool does and does not do

The tool reads the published BMI and comorbidity criteria from each payer's clinical policy bulletin and tells you whether you meet the medical-necessity threshold. It does not guarantee that any specific payer will approve your surgery. Final coverage decisions are made by the payer at the prior-authorization stage and depend on documentation that this tool cannot evaluate (psychological evaluation, supervised diet records, smoking cessation status, facility accreditation, surgeon network status, prior failed weight-loss attempts, etc.).

The academic standards

Two guidelines define the academic landscape:

• NIH 1991 Consensus [1] — BMI ≥ 40, or BMI ≥ 35 with at least one serious comorbidity. The foundational standard cited by Medicare and most commercial insurers for three decades.
• ASMBS / IFSO 2022 Indications [2] — lowered the threshold to BMI ≥ 35 regardless of comorbidities, and added a BMI 30-34.9 + metabolic disease pathway. The current academic standard, but most US payers have not yet adopted it.

The payer landscape

Six US payers are included, each linked to its published clinical policy bulletin or coverage determination:

• Medicare NCD 100.1 [3]: BMI ≥ 35 + at least one comorbidity, prior failure of medical management, ASMBS Center of Excellence or MBSAQIP-accredited facility. Covers RYGB, BPD/DS, sleeve gastrectomy, and LAGB.
• Aetna CPB 0157 [4]: BMI ≥ 40 alone or ≥ 35 with comorbidity (≥ 37.5 / ≥ 32.5 for Asian ancestry), 12 supervised diet sessions on separate dates within 2 years (≈6-month elapsed), psychological evaluation, 2-year documented obesity duration.
• Cigna 0051 [5]: BMI ≥ 40 alone or ≥ 35 with comorbidity, documented prior failed weight loss, preauthorization required, psychological evaluation, nutritional counseling.
• UnitedHealthcare [6]: BMI ≥ 40 alone or ≥ 35 with comorbidity, MBSAQIP-accredited facility or equivalent program, psychosocial-behavioral evaluation.
• BCBS FEP 7.01.47 [7]: BMI ≥ 40 alone, or ≥ 35 with comorbidity, or ≥ 30 with type 2 diabetes (a Class 1 + T2D pathway). State licensee policies vary.
• Humana [8]: BMI ≥ 40 alone or ≥ 35 with comorbidity, 6-month physician-supervised weight loss program, multidisciplinary preparatory regimen, psychological evaluation.

Why so many payers say BMI ≥ 40 vs ASMBS 2022 BMI ≥ 35

Payer policies update on slower cycles than academic guidelines. The ASMBS 2022 update [2] is the current academic recommendation, but most commercial insurers and Medicare still use the older NIH 1991 threshold. This means that a patient with BMI 36 and no comorbidities is academically eligible under ASMBS 2022 but not insurance-eligible under most payers. The tool surfaces this gap explicitly so patients understand which standard applies to which decision.

Outcomes evidence underlying the eligibility criteria

The clinical guidelines are anchored on:

• STAMPEDE [9]: Schauer 2017 NEJM 5-year RCT showed bariatric surgery + medical therapy produced −19% to −23% body weight loss vs −5% on intensive medical therapy alone, with substantially better T2D remission.
• Adams 2007 [11]: Long-term mortality after gastric bypass cohort (n=15,850) reported a 40% reduction in all-cause mortality at 7 years post-surgery vs matched non-surgical controls.
• Sjöström 2007 (SOS) [10]: The Swedish Obese Subjects study reported sustained mortality benefit (HR 0.71 at 10.9 years; HR 0.77 at 24 years).
• Buchwald 2004 [12]: Meta-analysis of 22,094 patients across 136 studies reported mean excess weight loss of 61.2% and T2D resolution in 76.8%.

Important disclaimer

This tool is for educational purposes only and does not constitute medical advice or a payer coverage determination. Payer policies change quarterly and vary by plan, by employer group, and by state. Final eligibility for bariatric surgery requires evaluation by a qualified bariatric surgeon at an accredited center, prior authorization from your specific insurance plan, and the documentation specified by that plan. Patients with active eating disorders, untreated severe depression, or uncontrolled substance use should not pursue bariatric surgery without addressing those conditions first. Every payer criterion in this tool was independently verified against the cited source URL by a research subagent on 2026-04-07.

Related research and tools

• Bariatric surgery vs GLP-1s in 2026 — full evidence comparison and outcome data
• GLP-1 surgery and anesthesia (ASA) guidance — perioperative GLP-1 management
• GLP-1 BMI calculator — drug eligibility (Wegovy, Zepbound, Foundayo)
• GLP-1 protein & macro calculator — for muscle preservation pre- and post-operatively
• GLP-1 insurance coverage audit — payer patterns for GLP-1 vs surgery
• Insurance directory — full coverage detail by insurer