Health Coverage of Gastric Surgeries

Gastric bypass (bariatric) surgery is one treatment option for individuals with morbid (clinically severe) obesity. The number of bariatric surgeries performed in the United States each year has risen steadily from just under 13,000 in 1998 to over 177,000 in 2006, and demand for the procedure continues to increase. The availability of health coverage for gastric bypass, however, is highly variable and dependent upon a number of factors including insurance company criteria, employer benefit plans, type of gastric bypass procedure, and state laws governing insurance coverage. In fact, as the number of bariatric procedures has increased over the past few years, it has become increasingly challenging for individuals to obtain insurance coverage or approval for the surgery. Insurers cite escalating costs, surgery risks, inexperienced surgeons, and unknown long-term outcomes as reasons to exclude, deny, or limit coverage for gastric bypass procedures.

Generally accepted criteria for coverage of gastric bypass procedures are derived from the National Institutes of Health (NIH) consensus statement on gastrointestinal surgery for severe obesity published in 1991. Gastric bypass surgery can be considered as a treatment option for individuals who have a body mass index (BMI) of at least 40, or for individuals with a BMI of at least 35 who also have a serious obesity-related condition such as cardiovascular disease or diabetes. BMI is calculated by dividing a person's weight in kilograms by his or her height in meters squared [(kg)/height (m2)]. The criteria represent the minimum starting point, however, for gastric bypass surgery as insurance companies and employers may put in place more restrictive criteria for obtaining surgery. (Gastric bypass providers may also apply more stringent criteria, but those will not be covered here.)

Insurance coverage for gastric bypass procedures is not guaranteed; in fact, it is highly variable depending upon a number of factors. Employers can choose whether to offer gastric bypass coverage as part of the benefits package. Employers who are self-insured, that is, they assume the costs of coverage, often elect not to offer coverage for bariatric surgery because of the initial cost for the procedure. In addition, cost savings from bariatric surgery, such as reduced need for medications and greater employee productivity may not be realized until two to three years or more after surgery. Some employers choose to offer bariatric surgery coverage but at an extra cost to employees.

Insurance companies vary widely in coverage of gastric bypass. Some insurers provide coverage with very few out-of-pocket costs for the insured; others limit, or cap, the amount of reimbursement paid for the procedures and related costs, while still other insurance [Page 352]companies exclude coverage for gastric bypass altogether. Very few states require insurance companies to specifically cover the cost of gastric bypass surgery; rather, the requirements are to provide coverage for medically necessary treatments or procedures. This requirement leaves room for interpretation about what constitutes as medical necessity, and individuals may be denied approval for bariatric surgery on the grounds that the procedure does not constitute a medical necessity, despite satisfying the general criteria set forth by the NIH. Denials can be appealed; however, this is a time-consuming process and there is no guarantee that a denial can be overturned.

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