BCBS HMO New England

Hi all! I just got this random email from a fellow-OHer (she didn't say which state she was from). All she said was that BCBS will have a written exclusion for all bariatric procedures as of January 1, 2006. I've had my referral for over 2 months now, and can not get in to see the surgeon until January 3rd. I'm going to call BCBS tomorrow and ask them if this is true. Does anyone else have insight? Jennie

I know nothing.. but interestingly...I was on the BC national website jsut today--looking for something else. . They offer reports on procedures for the entire BC to follow. There was one on banding....and it basically was inconclusive for the data. If I read it correctly...it said that the surgeries do not meet TEC standards. Now I don't know if individual States follow this or not. To get there...www.bluecross.com click lower right ....Technology Evaluation Center and then the report is listed. I've attached it here...might be too long. Joan ******************************************************* Newer Techniques in Bariatric Surgery for Morbid Obesity: Laparoscopic Adjustable Gastric Banding, Biliopancreatic Diversion, and Long-Limb Gastric Bypass Assessment Program Volume 20, No. 5 August 2005 Executive Summary Morbid obesity, generally defined as a body-mass index (BMI) of 40 kg/m2 or greater, is associated with excess mortality and a high burden of obesity-related morbidities. Nonsurgical treatments (i.e., lifestyle modifications, behavioral therapy, medications) are first-line therapies for obesity; however, the majority of morbidly obese patients do not achieve substantial weight loss with these approaches. Bariatric surgery is a therapeutic option for patients who have failed conservative treatment. Surgical treatment has been employed for several decades, and a large number of clinical series have demonstrated success in achieving substantial weight loss (TEC Special Report; Vol. 18, No. 9). The most marked improvements are in diabetes. Reduction in depression and anxiety has also been reported. Hypertension is reduced in the first 2 years after surgery, but the improvement is not sustained over the long term. Gastric bypass with Roux-en-Y anastomosis (GBY) has been considered the bariatric surgery of choice in the U.S, and this is supported by a substantial body of literature. Comparative trials have shown gastric bypass with Roux-en-Y anastomosis to be superior to alternative procedures such as vertical-banded gastroplasty (9 studies, n=3,780), horizontal gastroplasty (2 studies, n=261), and open gastric banding (2 studies, n=283). Roux-en-Y gastric bypass achieves greater weight loss and can be performed with low rates of morbidity and mortality. In recent years, less-invasive techniques have been applied to bariatric surgery, and offer potential benefits compared to open gastric bypass. Laparoscopic adjustable gastric banding is less technically complex than other procedures, thus, potentially lowering short-term complications even further. Laparoscopic adjustable gastric banding has the additional advantage of reversibility, which is unique among bariatric surgery procedures. Another recent trend is the use of variations on gastric bypass (e.g., biliopancreatic diversion, long-limb gastric bypass) in attempts to maximize weight loss in patients with super-obesity (BMI >50 kg/m2). A previous TEC Assessment completed in 2003 (Vol. 18, No. 10) concluded that less-invasive procedures and alternatives to gastric bypass did not meet the TEC criteria. The purpose of this Assessment is to update the literature on laparoscopic adjustable gastric banding, biliopancreatic diversion, and long-limb gastric bypass to determine whether the current evidence base allows more definitive conclusions to be drawn on the efficacy of weight loss and the rates of adverse events for these newer procedures. Based on the available evidence, the Blue Cross and Blue Shield Medical Advisory Panel made the following judgments about whether newer approaches to bariatric surgery (i.e., laparoscopic adjustable gastric banding, biliopancreatic diversion, and long-limb gastric bypass) for patients with morbid obesity meet the Blue Cross and Blue Shield Association Technology Evaluation Center (TEC) criteria. 1. The technology must have final approval from the appropriate governmental regulatory bodies. The interventions under consideration are surgical procedures and are not subject to U.S. Food and Drug Administration (FDA) regulations. However, certain devices that may be used as part of the procedure may be subject to FDA approval. The Lap-Band® system received Premarket Application (PMA) approval by the FDA in June 2001 for use in morbidly obese patients. No other devices are currently FDA approved for use in bariatric surgery. 2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes. Laparoscopic Adjustable Gastric Banding. The evidence is not sufficient to form conclusions on the benefit/risk ratio of LAGB compared to gastric bypass. While a number of new studies have been reviewed since 2003 that add to the evidence base, there remain deficiencies in the literature, particularly for determining the rates of long-term adverse events. The available comparative trials reinforce the conclusion of the 2003 Assessment that LAGB results in less weight loss at 1 year compared to GBY. This difference may lessen by years 2 to 3, but appears to remain substantial. The data from the large number of single-arm series are sufficient to confirm that short-term complications are low with LAGB. Mortality from the procedure is rare, and other postoperative complications occur at low rates, lower than those for open or laparoscopic gastric bypass. The rates of long-term complications cannot be reliably determined from the available data. For LAGB, the frequency of long-term complications is higher than short-term complications, but there is a wide range of reported values and a great deal of uncertainty concerning the summary values reported in this Assessment. This uncertainty derives from the lack of systematic surveillance and reporting of long-term adverse events, and from the incomplete follow-up that is seen in most of these trials. As a result, it is not possible to determine the overall benefit/risk ratio for LAGB from the available data. Long-term prospective trials that have adequate follow-up and report systematically on complications for at least 3-5 years are needed to remediate these important deficiencies in the current evidence base. Biliopancreatic Diversion. The evidence is not sufficient to support conclusions on the benefit/risk ratio for BPD compared with gastric bypass. While there have been numerous studies of BPD published since the 2003 Assessment, there remains a lack of high-quality comparative trials. The available evidence, derived from 1 comparative trial and 7 single-arm series, suggests that weight loss outcomes at 1 year are in the same range as for gastric bypass. These data are not sufficient to distinguish small differences in weight loss between the 2 procedures, but the data do not support the hypothesis that BPD results in greater weight loss than GBY. Complication rates are poorly reported in these trials. The data suggest that mortality is low (approximately 1%) and in the same range as for GBY. However, rates of other complications, especially long-term complications, cannot be determined from these data. Limited data suggests that long-term nutritional and vitamin deficiencies occur at a high rate following BPD. The rates of nutritional deficiencies and the consequences of these deficiencies require further investigation. Long-limb Gastric Bypass. The evidence on LL-GBY is not sufficient to form conclusions on the efficacy or safety of LL-GBY compared to standard GBY. A total of 6 comparative trials of LL-GBY vs. standard GBY and 1 single-arm study of LL-GBY were reviewed for this Assessment. The majority of the comparisons of weight loss in these studies, including the strongest evidence contained in 2 RCTs, report that weight loss at 1 year does not differ between the two groups. Thus, this evidence does not support the hypothesis that weight loss is better with LL-GBY. The evidence on the super-obese population is weak, and not sufficient to conclude whether the LL-GBY is superior for this group of patients. The evidence on adverse events of this procedure is not sufficient to form conclusions on the comparative rates of adverse events between the two procedures. 3. The technology must improve the net health outcome. For the procedures reviewed (LAGB, BPD, LL-GBY), there is insufficient evidence to conclude whether these procedures improve the net health outcome since the evidence is not sufficient to permit conclusions on their overall benefit/risk ratio. 4. The technology must be as beneficial as any established alternatives. For the procedures reviewed (LAGB, BPD, LL-GBY), there is insufficient evidence to conclude whether these procedures improve the net health outcome since the evidence is not sufficient to permit conclusions on their overall benefit/risk ratio compared with open gastric bypass. 5. The improvement must be attainable outside the investigational settings. For the procedures reviewed (i.e., laparoscopic adjustable gastric banding, biliopancreatic diversion, long-limb gastric bypass), improvement in health outcomes has not been demonstrated in the investigational setting. Based on the above, laparoscopic adjustable gastric banding, biliopancreatic diversion, and long-limb gastric bypass do not meet the TEC criteria. Full Study Newer Techniques in Bariatric Surgery for Morbid Obesity: Laparoscopic Adjustable Gastric Banding, Biliopancreatic Diversion, and Long-Limb Gastric Bypass Full studies are in PDF format. You will need Adobe Acrobat Reader to view all studies. Download Adobe Acrobat Reader here. TEC Assessment Index NOTICE OF PURPOSE: TEC Assessments are scientific opinions, provided solely for informational purposes. TEC Assessments should not be construed to suggest that the Blue Cross Blue Shield Association, Kaiser Permanente Medical Care Program or the TEC Program recommends, advocates, requires, encourages, or discourages any particular treatment, procedure, or service; any particular course of treatment, procedure, or service; or the payment or non-payment of the technology or technologies evaluated. KEYWORDS: Surgery/Surgical Alternatives/Interventional Radiology (category); Gastroenterology (category); adjustable gastric band; bariatric surgery; bilio-pancreatic diversion; BMI; BPD; body mass index; diabetes; diabetes mellitus; distal gastric bypass; dumping syndrome; duodenal switch procedure; gastric band; gastric banding; gastric bypass; HGP; gastric resection; gastroesophageal reflux disease; gastrogastrostomy; GERD; horizontal gastroplasty; hypocalcemia; iron deficiency anemia; laparoscopic banding; laparoscopic gastric band; horizontal gastroplasty; hypertension; intraperitoneal surgery; laparoscopic gastric bypass; laparoscopic bypass; laparoscopic surgery; jejunal-ileal bypass; Lap-Band; LLGBY; long-limb gastric bypass; malabsorptive procedures; morbid obesity; morbidly obese; nonsurgical treatments; obese; obesity; obesity surgery; open gastric banding; open gastric bypass; peritonitis; restrictive procedures; roux-en-y; roux-en-y anastomosis; silastic ring gastroplasty; SRGP; severe obesity; super-obesity; surgery; Swedish adjustable gastric band; Type II diabetes; Type II DM; vertical banded gastroplasty; VBGP; vitamin deficiency; weight loss Home |What Is TEC? |Kaiser Collaboration |Evidence-Based Medicine |AHRQ EPC TEC Assessments | TEC Criteria |Medical Advisory Panel |Contact Us Privacy Statement |Terms & Conditions Copyright ©2005 Blue Cross Blue Shield Association. 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Thanks Joan! I did call them a few months ago about the lap band and BCBS told me that they still consider it experimental and wouldn't cover it, so I would have to go with the RNY - which they do cover (hopefully after 1/06) Hopefully this is all a misunderstanding and an uninformed poster who gave me this 'information' Jennie!

Hi Jennie, I am confused that they would have told you a few months ago they didn't cover the lap-band. I was approved the end of November and just had my lap-band done on 12/21. I have HMO Blue through BCBS and was approved first try. As to whether or not they are changing their policy I find insurance companies impenetrable at the best of times (how they prefer it BTW ). In addition to calling BCBS you might try your surgeon's office. Good Luck, Kim

Hey Kim, That is really weird. I know i had two phone calls with them and both times they explicitly told me NO to the Lap Band. I dont get them sometimes! Weird. I'll call them again tomorrow. Jennie

Something you might try is asking your doctor's office. They usually have someone there who deals with the insurance companies all day long and is up to speed on who covers what, etc. Is it possible that it is company related? We are self-employed so we have a very basic policy with BCBS but a bigger employer might have imposed a bunch of restrictions we didn't explore.... Kim

I just had rny on 1/4/06 and my insurer is HMO Blue New England. My understanding is that it depends on the company you work for,ie, what coverages they purchase. Bill