The evidence for the benefits of bariatric surgery continues to accumulate and has become almost overwhelming at this point. In the last year, three significant studies in major medical journals (the New England Journal of Medicine and the Journal of the American Medical Association) have confirmed that bariatric surgery helps people live longer and alleviates comorbid diseases such as diabetes, hypertension, sleep apnea and back and joint pain. Morbid obesity is a serious disease, and failure to serve the population requesting treatment is a medical, economic and public health concern.
Denials and Prerequisites
A recent article in the journal Surgery for Obesity and Related Diseases confirmed what I suspect many people already know: insurance denials for bariatric surgery have increased significantly over the last several years. The authors of the article looked at the reasons that prevented prospective patients from undergoing bariatric surgery and examined their own practice records from 2001-2005. They found that in 30 percent of cases where patients did not have surgery, it was for insurance-related reasons–either outright denials or unobtainable coverage prerequisites. As the popularity of bariatric surgery increased, so did the number of insurance denials. This suggests that the increasing denials and prerequisites were not the result of medical evidence, but simply a way to prevent patients from accessing this type of care. In fact, as mentioned earlier, medical evidence demonstrating the benefits of bariatric surgery was continuing to accumulate at the very time that insurance denials were increasing.
The coverage prerequisites that were noted in the study included documented evidence of 24 months of medically supervised weight loss, a five-year documented weight history, having been diagnosed with morbid obesity for more than five years, and taking part in an MD-supervised exercise program for six months. Now, almost all patients who are considering bariatric surgery have done many of these things, but providing written evidence can be difficult. Without a paper trail proving you have done these things, it becomes difficult to obtain coverage, and for a patient who doesn’t have a two- to five-year weight history, the only way to get one is to wait two to five years. This seems like an insurmountable barrier to most people, and many quite understandably give up in frustration.
Such administrative barriers would be unimaginable with any other medical condition. Imagine an insurance carrier requiring patients to prove they had diabetes, hypertension, coronary artery disease, rheumatoid arthritis or virtually any other medical condition for five years before authorizing treatment. Yet such coverage prerequisites are becoming more common for treatment of morbid obesity.
Educate Yourself
What is a patient to do? The first step is to learn as much as you can and become your own advocate. Find out the requirements of your particular insurance carrier prior to seeking consultation with a bariatric surgeon. If you are considering bariatric surgery at all, you should start doing this now. Many patients arrive at my office after months or years of thinking about the surgery and trying other options such as diet, exercise and weight loss medications, and it can be quite discouraging for them when they confront these administrative barriers.
Most insurance companies’ requirements can be obtained from the company’s website. If their homepage has a search engine, you can enter “obesity surgery” or “weight loss surgery” to find the policy statements for that particular insurance company regarding bariatric surgery.
I frequently recommend that patients print out these requirements and give a copy to their primary care provider (PCP). Notes from your PCP can make or break an approval request for bariatric coverage. Remember, if it isn’t documented, it didn’t happen, and if the PCP doesn’t know what is required, his or her documentation may not be acceptable to the insurance company. This again results in coverage denials or delays.
Work with Your Primary Care Provider
When you visit your PCP, ask him or her to teach you about diets, calorie counts and weight loss, and to document having done so. If your PCP doesn’t have the time or the expertise, he or she can refer you to a registered dietician for formal nutritional counseling.
You should also make sure you get weighed at every visit, even if you are being seen for something unrelated, such as a cold. Many morbidly obese patients refuse to be weighed out of fear or embarrassment, or because they are above the weight limit of the scale (for instance, if they weigh more than 350 pounds). If this is the case for you, make sure they document that you were above the weight limit, not simply that you didn’t get weighed. This helps you build a paper trail to prove your history of obesity.
Work with Your Employer
Another approach is to talk with the human resources department of your employer. If you work for a large company, they will hopefully recognize the benefits of weight loss surgery, and they may be able to work with the insurance carrier to obtain more reasonable requirements.
Remember, bariatric surgery is clearly the most effective treatment yet devised for morbid obesity. The evidence for its effectiveness continues to accumulate, and it should be available to any morbidly obese patient who wishes this type of treatment. If bariatric surgery is something you are considering, you should start finding out what will be required right away. The coverage requirements can clearly be a burden, but if you manage them properly, you can get approved and start enjoying the benefits of this lifesaving surgery!
Information courtesy of Michael Bilof, MD, FACS.
Michael Bilof, MD, FACS, is an ASMBS Center of Excellence surgeon who exclusively practices bariatric surgery in West Orange, New Jersey.
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