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Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies.

Authors
  • Gebran, Selim G1
  • Knighton, Brooks2
  • Ngaage, Ledibabari M1
  • Rose, John A3
  • Grant, Michael P1
  • Liang, Fan1
  • Nam, Arthur J1
  • Kavic, Stephen M1
  • Kligman, Mark D1
  • Rasko, Yvonne M4, 5
  • 1 Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
  • 2 University of Maryland School of Medicine, Baltimore, MD, USA.
  • 3 Department of Plastic & Reconstructive Surgery, The Johns Hopkins University, Baltimore, MD, USA.
  • 4 Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA. [email protected]
  • 5 Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD, 21230, USA. [email protected]
Type
Published Article
Journal
Obesity Surgery
Publisher
Springer-Verlag
Publication Date
Nov 20, 2019
Identifiers
DOI: 10.1007/s11695-019-04243-2
PMID: 31749107
Source
Medline
Keywords
Language
English
License
Unknown

Abstract

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. 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. 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%). 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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