The approval process in the US seems like a hardship. Here in PR is easier for the patients, if you have a BMI of 35 or higher with comorbidities or 40 or higher, all insurance companies must approve your surgery within 15 days of submitting your application provided you include evidence of having tried any weight loss treatment and or exercise plan without success, and the basic medical evidence. Then with the approval you begin the process of nutricionist, and all the evaluations needed prior surgery.