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Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies

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Abstract

Background

Bariatric surgery remains underutilized at a national scale, and insurance company reimbursement is an important determinant of access to these procedures. We examined the current state of coverage criteria for bariatric surgery set by private insurance companies.

Methods

We surveyed medical policies of the 64 highest market share health insurance providers in the USA. ASMBS guidelines and the CMS criteria for pre-bariatric evaluation were used to collect private insurer coverage criteria, which included procedures covered, age, BMI, co-morbidities, medical weight management program (MWM), psychosocial evaluation, and a center of excellence designation. We derive a comprehensive checklist for pre-bariatric patient evaluation.

Results

Sixty-one companies (95%) had defined pre-authorization policies. All policies covered the RYGB, and 57 (93%) covered the LAGB or the SG. Procedures had coverage limited to center of excellence in 43% of policies (n = 26). A total of 92% required a BMI of 40 or above or of 35 or above with a co-morbidity; however, 43% (n = 23) of policies covering adolescents (n = 36) had a higher BMI requirement of 40 or above with a co-morbidity. Additional evaluation was required in the majority of policies (MWM 87%, psychosocial evaluation 75%). Revision procedures were covered in 79% (n = 48) of policies. Reimbursement of a second bariatric procedure for failure of weight loss was less frequently found (n = 41, 67%).

Conclusions

A majority of private insurers still require a supervised medical weight management program prior to approval, and most will not cover adolescent bariatric surgery unless certain criteria, which are not supported by current evidence, are met.

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References

  1. Sjostrom L. Review of the key results from the Swedish obese subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013;273(3):219–34.

    Article  CAS  Google Scholar 

  2. Courcoulas AP, Christian NJ, Belle SH, et al. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310(22):2416–25.

    CAS  PubMed  PubMed Central  Google Scholar 

  3. Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA. 2012;308(11):1122–31.

    Article  CAS  Google Scholar 

  4. Aminian A, Andalib A, Khorgami Z, et al. A nationwide safety analysis of bariatric surgery in nonseverely obese patients with type 2 diabetes. Surg Obes Relat Dis. 2016;12(6):1163–70.

    Article  Google Scholar 

  5. Estimate of Bariatric Surgery Numbers, 2011-2017. American Society for Metabolic and Bariatric Surgery. https://asmbsorg/resources/estimate-of-bariatric-surgery-numbers Published June 26, 2018. Accessed January 21, 2019.

  6. Hennings DL, Baimas-George M, Al-Quarayshi Z, et al. The inequity of bariatric surgery: publicly insured patients undergo lower rates of bariatric surgery with worse outcomes. Obes Surg. 2018;28(1):44–51.

    Article  Google Scholar 

  7. Stanford FC, Jones DB, Schneider BE, et al. Patient race and the likelihood of undergoing bariatric surgery among patients seeking surgery. Surg Endosc. 2015;29(9):2794–9.

    Article  Google Scholar 

  8. Bae J, Shade J, Abraham A, et al. Effect of mandatory centers of excellence designation on demographic characteristics of patients who undergo bariatric surgery. JAMA Surg. 2015;150(7):644–8.

    Article  Google Scholar 

  9. English W, Williams B, Scott J, et al. Covering bariatric surgery has minimal effect on insurance premium costs within the Affordable Care Act. Surg Obes Relat Dis. 2016;12(5):1045–50.

    Article  Google Scholar 

  10. Colameco C, Weiner J. Essential Health Benefits: 50-state variations on a theme. Penn Leonard Davis Institute of Health Economics and Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2014/10/essential-health-benefits%2D%2D50-state-variations-on-a-theme.html. Published February 8, 2018. Accessed January 19, 2019.

  11. Centers for Medicare & Medicaid Services. Decision memo for bariatric surgery for the treatment of morbid obesity (CAG-00250R). https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx. Accessed June 13, 2019.

  12. Menzo EL, Hinojosa M, Carbonell A, et al. American Society for Metabolic and Bariatric Surgery and American Hernia Society consensus guideline on bariatric surgery and hernia surgery. Surg Obes Relat Dis. 2018;14(9):1221–32.

    Article  Google Scholar 

  13. Nguyen NT, Blackstone RP, Morton JM, Ponce J, Rosenthal RJ. The ASMBS Textbook of Bariatric Surgery. Vol. 1 Bariatric Surgery. 2015.

    Google Scholar 

  14. Centers for Medicaid and Medicare Services. Medicare national coverage determinations manual: chapter 1, part 2 (sections 90-160.26). https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=258&NcaName=Bariatric+Surgery+for+the+Treatment+of+Morbid+Obesity&CoverageSelection=National&KeyWord=obesity&KeyWordLookUp=Title&KeyWordSearchType=And&where=index&nca_id=2. Published 2014. Accessed January 20, 2019.

  15. Cassie S, Menezes C, Birch DW, et al. Effect of preoperative weight loss in bariatric surgical patients: a systematic review. Surg Obes Relat Dis. 2011;7(6):760–7. discussion 767

    Article  Google Scholar 

  16. Tewksbury C, Williams NN, Dumon KR, et al. Preoperative medical weight management in bariatric surgery: a review and reconsideration. Obes Surg. 2017;27(1):208–14.

    Article  Google Scholar 

  17. Gibbons LM, Sarwer DB, Crerand CE, et al. Previous weight loss experiences of bariatric surgery candidates: how much have patients dieted prior to surgery? Obesity (Silver Spring). 2006;14(Suppl 2):70S–6S.

    Article  Google Scholar 

  18. Glenn NM, Raine KD, Spence JC. Mandatory weight loss during the wait for bariatric surgery. Qual Health Res. 2015;25(1):51–61.

    Article  Google Scholar 

  19. Billy H, DeMaria EJ. Comment on: insurance-mandated preoperative diet and outcomes after bariatric surgery. Surg Obes Relat Dis. 2018;14(5):636–9.

    Article  Google Scholar 

  20. Horwitz D, Saunders JK, Ude-Welcome A, et al. Insurance-mandated medical weight management before bariatric surgery. Surg Obes Relat Dis. 2016;12(3):496–9.

    Article  Google Scholar 

  21. Schneider A, Hutcheon DA, Hale A, et al. Postoperative outcomes in bariatric surgical patients participating in an insurance-mandated preoperative weight management program. Surg Obes Relat Dis. 2018;14(5):623–30.

    Article  Google Scholar 

  22. Cohen RV, Luque A, Junqueira S, et al. What is the impact on the healthcare system if access to bariatric surgery is delayed? Surg Obes Relat Dis. 2017;13(9):1619–27.

    Article  Google Scholar 

  23. Brethauer S. ASMBS Position statement on preoperative supervised weight loss requirements. Surg Obes Relat Dis. 2011;7(3):257–60.

    Article  Google Scholar 

  24. Kim JJ, Rogers AM, Ballem N, et al. American Society for M, bariatric surgery clinical issues C. ASMBS updated position statement on insurance mandated preoperative weight loss requirements. Surg Obes Relat Dis. 2016;12(5):955–9.

    Article  Google Scholar 

  25. Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity. 2013;21(Suppl 1):S1–27.

    Article  CAS  Google Scholar 

  26. Zwintscher NP, Azarow KS, Horton JD, et al. The increasing incidence of adolescent bariatric surgery. J Pediatr Surg. 2013;48(12):2401–7.

    Article  Google Scholar 

  27. Pratt JSA, Browne A, Browne NT, et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surg Obes Relat Dis. 2018;14(7):882–901.

    Article  Google Scholar 

  28. Flum DR, Kwon S, MacLeod K, et al. The use, safety and cost of bariatric surgery before and after Medicare’s national coverage decision. Ann Surg. 2011;254(6):860–5.

    Article  Google Scholar 

  29. Paulus GF, de Vaan LE, Verdam FJ, et al. Bariatric surgery in morbidly obese adolescents: a systematic review and meta-analysis. Obes Surg. 2015;25(5):860–78.

    Article  Google Scholar 

  30. Black JA, White B, Viner RM, et al. Bariatric surgery for obese children and adolescents: a systematic review and meta-analysis. Obes Rev. 2013;14(8):634–44.

    Article  CAS  Google Scholar 

  31. Treadwell JR, Sun F, Schoelles K. Systematic review and meta-analysis of bariatric surgery for pediatric obesity. Ann Surg. 2008;248(5):763–76.

    Article  Google Scholar 

  32. White B, Doyle J, Colville S, et al. Systematic review of psychological and social outcomes of adolescents undergoing bariatric surgery, and predictors of success. Clin Obes. 2015;5(6):312–24.

    Article  CAS  Google Scholar 

  33. Love KM, Mehaffey JH, Safavian D, et al. Bariatric surgery insurance requirements independently predict surgery dropout. Surg Obes Relat Dis. 2017;13(5):871–6.

    Article  Google Scholar 

  34. Palli SR, Rizzo JA, Heidrich N. Bariatric surgery coverage: a comprehensive budget impact analysis from a payer perspective. Obes Surg. 2018;28(6):1711–23.

    Article  Google Scholar 

  35. Gasoyan H, Tajeu G, Halpern MT, et al. Reasons for underutilization of bariatric surgery: the role of insurance benefit design. Surg Obes Relat Dis. 2018;

  36. Keith Jr CJ, Goss LE, Blackledge CD, et al. Insurance-mandated preoperative diet and outcomes after bariatric surgery. Surg Obes Relat Dis. 2018;14(5):631–6.

    Article  Google Scholar 

  37. Aminian A, Chang J, Brethauer SA, et al. American Society for M, bariatric surgery clinical issues C. ASMBS updated position statement on bariatric surgery in class I obesity (BMI 30-35 kg/m(2)). Surg Obes Relat Dis. 2018;14(8):1071–87.

    Article  Google Scholar 

  38. Patel S, Eckstein J, Acholonu E, et al. Reasons and outcomes of laparoscopic revisional surgery after laparoscopic adjustable gastric banding for morbid obesity. Surg Obes Relat Dis. 2010;6(4):391–8.

    Article  Google Scholar 

  39. Martin M, Beekley A, Kjorstad R, et al. Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis. Surg Obes Relat Dis. 2010;6(1):8–15.

    Article  Google Scholar 

  40. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19(2):127–40.

    Article  CAS  Google Scholar 

  41. Gebhart A, Young M, Phelan M, et al. Impact of accreditation in bariatric surgery. Surg Obes Relat Dis. 2014;10(5):767–73.

    Article  Google Scholar 

  42. Kim DD, Arterburn DE, Sullivan SD, et al. Economic value of greater access to bariatric procedures for patients with severe obesity and diabetes. Med Care. 2018;56:583–8.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA

    Selim G. Gebran, Ledibabari M. Ngaage, Michael P. Grant, Fan Liang, Arthur J. Nam, Stephen M. Kavic, Mark D. Kligman & Yvonne M. Rasko

  2. University of Maryland School of Medicine, Baltimore, MD, USA

    Brooks Knighton

  3. Department of Plastic & Reconstructive Surgery, The Johns Hopkins University, Baltimore, MD, USA

    John A. Rose

  4. Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD, 21230, USA

    Yvonne M. Rasko

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  1. Selim G. Gebran
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  2. Brooks Knighton
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  3. Ledibabari M. Ngaage
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  4. John A. Rose
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Correspondence to Yvonne M. Rasko.

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Gebran, S.G., Knighton, B., Ngaage, L.M. et al. Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies. OBES SURG 30, 707–713 (2020). https://doi.org/10.1007/s11695-019-04243-2

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