I think it's more of a therapy thing. They do the same with gastric bypass and the lap band, you have to prove that you're capable of following post-surgery instructions and actually lose weight. Kinda like giving an alcoholic a new liver, what's the point if you know they're not going to control themselves? Because she gained so much weight so quickly they did not give her the free surgery, in the finale she went back to 145 and kept it off and I thought they said they were gonna give her the surgery during the finale ceremony, but on her Facebook page (she has one) she later said that ABC (because the show used to sponsored on ABC before TLC bought it) wouldn't pay for the surgery so she had to pay for it herself at a later date.