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There's no doubt that Americans are getting heavier: Fifteen million are morbidly obese. According to a 2007 report by the Trust for America's Health, adult obesity rates exceed 25 percent of the population in 19 states. Worst off is Mississippi, which broke the 30 percent mark for adult obesity.
Bariatric surgery encompasses operations on the stomach such as gastric bypass (open and laparoscopic), laparoscopic adjustable gastric banding, and biliopancreatic diversion. These procedures dramatically restrict your ability to eat, thereby causing weight loss. You will wind up with a smaller stomach that's able to hold only a few onces. Eat too much and you will feel ill.
In addition, some weight-loss surgeries alter the digestion process, which limits absorption of calories and nutrients.
Despite the insurance obstacles, mounting evidence shows that surgery for morbid obesity is far more cost-effective than treating the conditions resulting from obesity. According to the American Society for Metabolic & Bariatric Surgery (ASMBS), mortality rates for bariatric surgery are 0.1 to 1 percent, depending on the procedure.
And after surgery, patients fare far better than they would have without it. A 2007 study reported in the New England Journal of Medicine showed that among gastric bypass surgery patients, death from diabetes was reduced by 92 percent, death by coronary artery disease was reduced by 56 percent, and death by cancer was reduced by 60 percent.
Your doctor might recommend surgery to help you lose weight if you have a body mass index (BMI) of more than 40 or a BMI of 35 or more coupled with an obesity-related disease like type 2 diabetes, heart disease or sleep apnea. To determine your BMI, divide your weight in kilograms by your height in meters squared. A BMI of 25 to 30 is considered overweight and 30 to 35 is considered obese. A person who is morbidly obese typically has a BMI above 35.
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The cost of obesity
- Each year obesity costs the nation more than $117 billion in medical costs and lost productivity; the direct cost of obesity totals $61 billion (with indirect costs at $56 billion).
- The cost of lost productivity due to obesity among Americans age 17 to 64 is $3.9 billion.
- Over 20 years (from age 30 to 50), people who are obese spend 36 percent more on health care services and 77 percent more on medications than cigarette smokers, who spend 21 percent and 28 percent, respectively.
- Obese individuals spend $395 more on medical care per year than non-obese individuals.
Source: ASMBS |
The average bariatric surgery costs about $25,000. Even with your doctor’s recommendation and coverage available from your health insurance policy, your health insurer might not pay for the surgery. According to the ASMBS, “Many insurance companies that do cover bariatric surgery place non-evidence-based barriers to discourage or delay patients from acquiring treatment." You’ll have a lot of hoops to jump through.
It's common to find insurers that will not pay for weight-loss surgery, yet these same insurers are paying for years of treating the conditions associated with obesity. Dr. Neil Hutcher, a practicing bariatric surgeon in Richmond, Va., and past president of the ASMBS, sees conditions such as diabetes and heart disease as "rooms in the house of obesity." Hutcher observes, "Health insurers treat each room in the house, but the roof is falling in."
It is highly unlikely that you'll find an individual health plan that covers weight-loss surgery, especially if you're already overweight. Your best chance for having insurance coverage for obesity surgery is through a group health plan. There is no standard health plan that covers bariatric surgery; an employer must specifically select it as an option.
Only four states mandate that treatment for morbid obesity be covered by group health plans: Georgia, Indiana, Maryland and Virginia. These mandates apply only to group plans, and even then not to group plans offered by self-funded companies. That’s where large employers take on their own financial risk of covering employee claims, and you probably won’t know if your employer is self-funded unless you ask.
The Council for Affordable Health Insurance estimates that mandated obesity coverage adds 1 to 3 percent to premium prices.
Know your policy terms before you schedule surgery. Is obesity surgery specifically excluded in your policy? Do you need pre-authorization?
Your insurer will likely require a full medical work-up along with the pre-authorization request plus documented physician-supervised weight-loss attempts. However, weight-loss programs themselves are rarely covered by insurance, and Weigh****chers and Jenny Craig don't count.
You'll find out exactly what documents you need when you make a pre-authorization request from your insurer; expect it to involve volumes of paperwork.
Coverage for weight-loss surgery varies widely, as do insurers’ definitions of “medically necessary." Here’s a sampling:
Aetna
Aetna does not offer any individual health plan that covers bariatric surgery. Most Aetna group HMO and POS plans exclude coverage of surgical operations, procedures or treatment of obesity unless approved by Aetna.
For Aetna plans that do cover bariatric surgery, here is a summary of the criteria for gastric bypass approval:
The patient must have been morbidly obese for five years with a BMI of 40 or more or have BMI greater than 35 in conjunction with any of the following: coronary heart disease, Type 2 diabetes mellitus, clinically significant obstructive sleep apnea, or medically refractory hypertension. In addition to that, you’ll have to:
1. Have attempted weight loss in the past without successful long-term weight reduction; and
2. Have participated in a “physician-supervised nutrition and exercise program" or a “multidisciplinary surgical preparatory regimen," each with their own criteria.
The list goes on and is available on the Aetna Web site under Clinical Policy Bulletin: Obesity Surgery.
CIGNA HealthCare
Bariatric surgery is specifically excluded under the standard CIGNA HealthCare plan, but employers can elect to include or exclude coverage for bariatric surgery in their group health plans. CIGNA says the majority of employers select a plan that covers the surgery.
When CIGNA coverage is available, a patient is required to have:
1. Reached age 18 or full skeletal growth. 2. A BMI of more than 40 for at least the past 24 months or a BMI of 35-29.9 for at least the past 24 months plus another significant problem, such as diabetes or hypertension.
3. Active participation within the last two years in a physican-directed weight-management program.
4. An evaluation within the past 12 months including: an evaluation by a surgeon qualified to do bariatric surgery recommending surgical treatment; a separate medical evaluation recommending bariatric surgery; clearance for surgery by a mental health provider; and a nutritional evaluation by a physician or registered dietician.
CIGNA HealthCare also covers medically necessary reversal of bariatric surgery when a patient has complications and, under certain cir****tances, covers revision of a previous bariatric procedure when the patient has not lost adequate weight.
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Finding a good bariatric surgeon
The American Society for Metabolic and Bariatric Surgery certifies "Centers of Excellence" around the country. To qualify, the hospital or institution must perform at least 125 bariatric surgeries per year collectively and the surgeon must have performed at least 125 bariatric surgeries himself and perform at least 50 per year.
The Center must also report long-term patient outcomes and have an on-site inspection to verify all data. In addition, the center must have a dedicated multi-disciplinary bariatric team that includes surgeons, nurses, medical consultants, nutritionists, psychologists and exercise physiologists.
To locate a bariatric surgery Center of Excellence near you, visit SurgicalReview.org.
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Even if you're lucky enough to have bariatric surgery coverage in your policy, brace yourself for a possibly long claims process. At best, you'll need mounds of documentation to show the surgery is medically necessary for you.
Or you may run into big roadblocks. Hutcher says he has witnessed a "hostile environment" for claims. Hutcher says there are three main ways that health insurers deny claims for bariatric surgery:
1. By contractual denial, meaning policies that specifically deny coverage.
2. By writing terms of the benefit so that no patient could possibly meet the requirements. For example, an insurer may not cover surgery if you have "an eating disorder." But if you weigh 400 lbs., how can you prove you don't have an eating disorder?
3. By "punitive reimbursement," or, "You'll be sorry you made this claim." Hutcher has seen patients get pre-authorization (which can take several months), get the surgery, and then require lifetime follow-up, only to receive $900 total from their insurer.
Hutcher compares submitting a claim for bariatric surgery to playing roulette: "And in roulette, you know the house always wins," he says.
So why do health insurers seem to fail to see the cost-effectiveness in paying for surgery versus paying for years and years of treating related conditions? Hutcher's theory, honed from decades as a practicing surgeon: "It's greed," he says, with a big dose of discrimination that "fat people don't deserve help."
"Health insurance is the only industry I know of where they consider doing what they are in business to do a loss," says Hutcher.
1. If your HMO plan doesn’t cover obesity surgery, change to a PPO plan at open enrollment if the PPO plan covers it.
2. Change to your spouse’s plan if it provides coverage.
3. Get a job with Microsoft. This is meant only partially tongue-in-cheek. Certain large employers cover weight-loss surgery as a commitment to employee health. According to ASMBS, these employers also offer coverage for weight-loss surgery: Intel, Toyota, FedEx Freight, and Harrah’s and Caesar’s Palace.
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The Professional Appealer
Walter Lindstrom is one of the best-known advocates in the country for folks seeking to overturn denials for weight-loss surgery. His California law practice (at ObesityLaw.com) evaluates potential appeals on a case-by-case basis by examining your insurance contract and medical records and then preparing a comprehensive written appeal that addresses all the possible reasons to approve the surgery. His office also represents you at grievance and appeal hearings and prepares you for those hearings. |
4. Consider paying out-of-pocket and ask your surgeon’s office about payment plans.
If your plan doesn’t exclude coverage yet you’re denied, appeal, appeal, appeal. You will probably need to provide further documentation of your need for the surgery as medically necessary.
Hutcher advises, "Call every day. Be the squeaky wheel."
Every health plan should have a clear appeals process. Find out exactly what it is and follow it to the letter. You might only have a limited time from the date you were denied or had the procedure to get an appeal under way, possibly only 60 days. Depending on your plan's procedure, you might have to start with a phone complaint, and then move to a written appeal.
Ask for your surgeon’s assistance in putting together solid documentation. Some bariatric surgeons’ offices even have "appeals experts" on staff who have experience in getting claims paid after denial.
Keep meticulous records of your contact with the insurer and your appeal.
There are two methods of appeal: internal and external. The internal appeal is to the insurer itself. An external appeal is to your state department of insurance or other governing body.
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