Digging Deeper: Insurance for Bariatric Surgery
From the insurance perspective, weight loss surgery
has always been considered “medically necessary.” This means that
weight loss surgery is not considered cosmetic, but rather is performed
to decrease the health risks associated with severe obesity.
Recently there have been several important articles in medical journals suggesting that weight loss surgery can actually increase
a person’s lifespan. One recent publication from Canada, which followed
a large number of patients during a 16 year period, showed that the risk of NOT having surgery
was associated with a four times higher death rate during the study
period versus patients who actually had weight loss surgery. This study
affirmed medical community’s “common knowledge” that severe obesity is associated with a shortened lifespan.
The Obesity Epidemic and Medicare
A number of recent studies have shown that the rate of severe obesity
has increased more than threefold in some regions during the past
decade. Some severely obese patients are disabled by their multiple
health problems. Many disabled obese patients have their health care
coverage through Medicare disability. Obesity related illnesses such as
diabetes, degenerative arthritis and sleep apnea are primary reasons for
disability coverage under Medicare.
Up until recently, Medicare had a clause stating that “obesity is not an
illness” in their policy statement. This clause was recently deleted
with the implication that obesity therefore must be considered an
illness. Medicare officials make a point to state that a statement
regarding “obesity as an illness” was not added to Medicare policy.
Medicare has traditionally covered weight loss surgery under the
so-called comorbid illnesses such as diabetes, high blood pressure,
sleep apnea etc. This meant that in order to qualify for surgical
treatment, a patient must have had one or more of these conditions in
order to be considered. Medicare never strictly followed the criteria of
the 1991 National Institutes of Health Consensus Development Panel,
which stated that severe obesity (body mass index/BMI of at least
40kg/m2 or slightly more than 100 pounds overweight) in of itself met
the criteria for weight loss surgery. The National Institutes of Health
(NIH) is heavily involved in a variety of research approaches with the
goal of slowing the obesity epidemic in the U.S. Ironically the NIH is
also a branch of our federal government.
The good news about Medicare’s recent ruling is that Medicare has
publicly acknowledged the tremendous burden obesity places upon health.
Medicare officials are also acutely aware of the increased cost of
treating all of the comorbid illnesses associated with obesity. It seems
likely that Medicare will endorse successful treatment strategies for
obesity with the goal of reducing cost.
Private Insurance Coverage
The tremendous increase in the number of surgical procedures performed
for the treatment of severe obesity has also become a focus of the
private insurance industry in the U.S. Weight loss surgery is expensive.
Even though patients may spend only two days in the hospital, these
operations are associated with use of expensive high technology
equipment, advanced nursing and surgical training, etc., all of which
drive up costs.
Unlike Medicare, private health insurance companies are focused on the
short term. This short term focus is due to the fact that these
for-profit corporations must report to their stockholders on a quarterly
basis. The industry is also acutely aware that the typical American
will spend less than 3 years with a given insurance carrier before
changing coverage. Hence, the long term cost savings of weight loss
surgery for a given insurance company may not be realized in this less
than 3 year time frame.
The increasing costs associated with weight loss surgery have lead many
insurance carriers to “change the rules” in terms of providing this
coverage. Up until recently, nearly all private insurance carriers
accepted the guidelines laid down by the 1991 National Institutes of
Health Consensus Development Panel as qualifications for weight loss
surgery. However, the recent explosion in the number of surgical
procedures has resulted in many carriers adding qualifiers to the NIH
guidelines, such as 6 or 12 months of a continuously medically
supervised diet. Though most patients seeking weight loss surgery have
accumulated years of failed diet treatments, these attempts are rarely
associated with written documentation of those efforts. An extended diet
program lacking written documentation over a 6 to 12 month period is,
unfortunately, not considered sufficient qualification by many private
The Future of Insurance Coverage for Bariatric Surgery
There has been considerable speculation regarding actions which might be
taken by private insurers in covering weight loss surgery during the
next year or so. Some carriers may add “riders” which permit coverage
but at a substantially increased cost to the insured, thereby passing
this cost on to the consumer. This approach, of course, transfers the
option of offering weight loss surgery coverage to the employer.
Individual employees are likely to have very little say in the matter.
The high cost of practicing bariatric surgery also plays a role in the
insurance coverage issue. Due to the complexity of obtaining insurance
coverage for patients seeking weight loss surgery, most practices have
at least one full time employee responsible for precertification of
What is precertification approval?
This is the procedure by which the insurance company reviews your
medical and dietary history prior to approving you for surgery.
Precertification has become a complicated, long-term process. Because
bariatric surgical procedures are complex and associated with
potentially serious complications, malpractice coverage for weight loss
surgery has become increasingly difficult and very expensive. Thus, the
increased overhead associated with weight loss surgery has driven many
surgeons to drop out of the HMOs and accept only patients with out of
network coverage. Patients with out of network coverage have the freedom
of choosing their surgeon, but are also likely to pay a portion of the
surgeon’s fee “out of pocket.”
These new qualifications have tremendously extended the waiting period
for patients seeking weight loss surgery. Many become discouraged by
repeated denials from their insurance carrier and stop seeking weight
loss surgery altogether. Other carriers such as Blue Cross Blue Shield
of Florida have taken a more direct approach by simply denying coverage
altogether. Although Blue Cross spokespersons have provided a number of
reasons for the decision to stop covering weight loss surgery, it seems
clear to most observers that the underlying reason is high cost.
The increased cost associated with weight loss surgery will likely drive
other carriers to add exclusionary clauses for coverage of these
operations into their new policies.
What Patients Should Do
During the period of open enrollment for health insurance, employees who
have the option to choose their health care coverage from a variety of
insurance plans should be aware of the language in their policy
regarding weight loss surgery. Ask these questions:
- Does the policy exclude it all together?
- Is coverage for surgery offered only at increased cost to the employer?
- If it is offered, what are the specific qualifications for coverage?
In the long term, it seems like weight loss surgery
will remain an option for prospective patients who meet
qualifications. It’s likely that qualifications will become better
defined, more reasonable, and consistent with knowledge of the
effectiveness of various surgical procedures.