Insurance and gastric Bypass Surgery

Most insurance companies will pay for gastric bypass surgery procedures that are medically necessary. Morbid obesity is a life threatening disease and it is normally covered.
Effective August 1, 2002, the Division of Medical Assistance implemented a new process for approval of gastric bypass surgery.

Aetna Insurance is now asking for the patients entire medical work-up along with the pre-authorization request as well as documented weight loss attempts supervised by a physician for the last 2 years. They also want documented weight history for the last 5 years.

Many insurance plans do not provide reimbursement for weight loss treatment. According to many practitioners, few private insurance indemnity plans or managed care organizations appear to cover the costs of obesity treatment regardless of whether the service is a medically supervised program of weight reduction or maintenance, nutrition counseling, surgery or a pharmaceutical product. The countless number of available insurance plans and ever changing policies have made it difficult to assess the extent to which obesity treatment and prevention services are covered by third party insurers. More data and better tracking is necessary to determine the health needs of persons with obesity.

Insurance Coverage Trends

A typical employer insurance plan could be similar to that of Wal-Mart. Benefits listed in their employee benefits booklet (1999) as “not payable for treatment or services” include charges from:

• medications and diet supplements which result from diet programs
• appetite control
• weight control
• treatment of obesity or morbid obesity, including gastric bypasses and stapling procedures even if the participant has other health conditions which might be helped by the reduction of weight.
  Obesity, Medicaid and Medicare

Medicaid does not cover obesity, and under Medicare, hospital and physician services for obesity are clearly excluded. Medicaid is a government program that provides health insurance to qualified individuals whose income level is below a certain point. Recipients of Medicaid are primarily women and children who are poor and members of minority groups. Given the high prevalence of obesity among those populations, it could be presumed that many Medicaid recipients are likely to have obesity. Medicare provides health insurance coverage to elderly citizens and disabled Americans who qualify by meeting criteria of the Social Security Administration (SSA) and completing a two-year waiting period.

Medicaid

• In 1990, Congress enacted the Omnibus Budget Reconciliation Act (OBRA), which funds state programs to provide pharmaceutical products to Medicaid recipients.
• A State may choose to exclude or restrict drugs or classes of drugs, or their medical uses for certain purposes. A State choosing to include outpatient drugs within its Medicaid program must cover, for their medically accepted indications, all Food and Drug Administration (FDA) approved prescription drugs of manufacturers that have entered into drug rebate agreements, with a few limited exceptions.
• Exceptions include drugs when used for: anorexia, weight loss or weight gain; to promote fertility; for cosmetic purposes or hair growth; for the symptomatic relief of cough and colds; or to promote smoking cessation.
• As a result of OBRA, the Department of Health and Human Services ordered states to cover Viagra for the treatment of erectile dysfunction while continuing to exclude anti-obesity agents.
  Nine states cover anti-obesity pharmaceutical products including Alaska, California, Kentucky, Montana, North Carolina, Oregon, Rhode Island, Washington and Wisconsin.
• One state, Arizona, covers products by specific managed health care plan.
• In 23 states, there is no specific language regarding coverage under Medicaid.
• In 29 states, anti-obesity products are specifically excluded in state Medicaid programs.

Medicare
The Medicare Coverage Manual defines obesity and the justification for certain treatment coverage by stating that:

• Obesity itself cannot be considered an illness. The immediate cause is a caloric intake, which is persistently higher than caloric output.
• Program payment may not be made for treatment of obesity alone since this treatment is not reasonable and necessary for the diagnosis or treatment of an illness or injury.

However, although obesity is not in itself an illness, it may be caused by illnesses such as hypothyroidism, Cushing's disease, and hypothalamic lesions. In addition, obesity can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Therefore, services in connection with the treatment of obesity are covered when such services are an integral and necessary part of a course of treatment for one of those illnesses.

Medicare’s limited coverage of obesity is difficult to understand when considering that it does cover services such as inpatient and outpatient alcohol detoxification and rehabilitation, inpatient and outpatient drug rehabilitation, and services for sexual impotence. It also covers chemical aversion therapy for the treatment of alcoholism even though the FDA has not approved the drugs commonly used in chemical aversion therapy for this application.
Gastric Bypass Surgery

Gastric bypass surgery for the treatment of obesity is covered on a limited basis. According to the Medicare Coverage Manual:

gastric bypass surgery, which is a variation of the gastrojejunostomy, is performed for patients with extreme obesity. Gastric bypass surgery for extreme obesity is covered under the program if:

1. it is medically appropriate for the individual to have such surgery.
2. the surgery is to correct an illness, which caused the obesity or was aggravated by the obesity.