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Obesity Surgery Coverage:
A Dilemma for Insurance Companies?
As obesity increases in the United States, researchers, doctors, and medical insurance companies are beginning to recognize the condition as a chronic and fatal health condition in and of itself. A motion made by the Department of Health and Human Services in July 2004 spearheaded a new revolution for the treatment of obesity with obesity surgery by changing the language in the Medicare Coverage Insurance Manual.
Once considered a "cosmetic issue" obesity was finally recognized as an illness. The new language maintains that obesity surgery and other obesity-related medical treatment is a medical necessity if it improves health and quality of life.
Obesity Surgery Insurance Coverage Standards
The qualifying standards for insurance companies regarding obesity surgery were set by the National Institute of Health in the mid 1980s.
- The patient is severely obese (BMI 40 or greater) or has a BMI of 35 to 39.9 and has other medical conditions, such as high blood pressure, sleep apnea, type 2 diabetes.
- Other methods of weight loss have been tried including diet, exercise or drugs therapy with no result.
- Daily routine activities, including work or family activity, cannot be performed and the quality of life is impaired.
- The patient understands the risks and the surgical procedure
- The patient is motivated to committing to a lifelong change of habits and behavior with regard to eating and exercise.
Certain risks were associated with obesity surgery, especially gastric bypass surgery. But by 1991 gastric bypass surgery and other obesity surgery were proven to be a reasonable alternative for curing obesity with benefits far outweighing the risks for obese individuals.
Risks of Gastric Bypass Surgery
Even with the standards set by National Institutes of Health and the new Medicare language some insurance companies are still reluctant to provide coverage for obesity surgery. Gastric bypass surgery, which is the most common obesity surgery, offers distinct benefits but is also associated with risks, including:
- need for additional follow-up surgery
- abdominal hernia
- development of gall stones
- anemia and osteoporosis due to vitamin and mineral depletion.
Yes or No on Obesity Surgery Coverage?
Insurance companies are reluctant to pay for procedures that have a history of complications or have low success rates. However, for every insurance company that would like to deny obesity surgery claims there are other insurance companies that recognize the positive impact of obesity surgery on quality of life. With the new Medicare guidelines more insurance companies are realizing the positive effects obesity surgery has on other serious illnesses like hypertension, type 2 diabetes, arthritis, stroke and cancers.
Getting Approval for Obesity Surgery
Here are some recommended steps to increase your chances of approval of insurance coverage of obesity surgery:
- Know your benefits. Your insurance company's Certificate of Coverage offers detailed descriptions about what benefits are covered under your policy.
- Your primary care physician can give you a referral to a bariatric surgeon. Bariatric surgeons are the doctors who perform obesity surgeries. A strong note of caution: Make sure your surgeon is qualified to perform gastric bypass surgery.
- Provide a detailed paper trail of your obesity-related medical care. Records from weight loss programs, exercise clubs, and other medical appointments provide proof of your efforts.
- Keep your own records and receipts.
- If you haven't heard from your insurance company shortly after the submission of your proposed claim, follow up. Insurance companies provide service to large populations.
Resources
American Obesity Association. (updated 2004). The OPERATE project: Obese people entitled to receive appropriate treatment equitably.
Association for Morbid Obesity Support. (nd). Getting authorization.
Strong Health. (nd). Is bariatric surgery right for you.
