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Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies

  • Selim G. Gebran
  • Brooks Knighton
  • Ledibabari M. Ngaage
  • John A. Rose
  • Michael P. Grant
  • Fan Liang
  • Arthur J. Nam
  • Stephen M. Kavic
  • Mark D. Kligman
  • Yvonne M. RaskoEmail author
Original Contributions

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.

Keywords

Bariatric Weight loss surgery Insurance Reimbursement 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors.

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Selim G. Gebran
    • 1
  • Brooks Knighton
    • 2
  • Ledibabari M. Ngaage
    • 1
  • John A. Rose
    • 3
  • Michael P. Grant
    • 1
  • Fan Liang
    • 1
  • Arthur J. Nam
    • 1
  • Stephen M. Kavic
    • 1
  • Mark D. Kligman
    • 1
  • Yvonne M. Rasko
    • 1
    • 4
    Email author
  1. 1.Department of SurgeryUniversity of Maryland School of MedicineBaltimoreUSA
  2. 2.University of Maryland School of MedicineBaltimoreUSA
  3. 3.Department of Plastic & Reconstructive SurgeryThe Johns Hopkins UniversityBaltimoreUSA
  4. 4.Division of Plastic Surgery, Department of SurgeryUniversity of Maryland Medical CenterBaltimoreUSA

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