Dr. Jacqueline Gerhart: Why isn't my gastric bypass surgery covered by insurance?
Madison, Wisconsin - UW Health Family Medicine physician Jacqueline Gerhart writes a column that appears Tuesdays on madison.com and in the Wisconsin State Journal. Columns are re-published here with permission.
Dear Dr. Gerhart,
I am overweight, and just got diagnosed with diabetes. I am debating gastric bypass surgery but my insurance won't cover it. My doctor said that my diabetes is related to my weight. So, why isn't the surgery covered?
Insurance companies and health care providers both want you to be healthy. However, they sometimes do not agree on the best way for you to become healthy. With the high health care costs in the United States, providers and insurance companies both try to provide quality care while being cost-effective. Finding the right way to balance quality and cost is often difficult to agree upon, and often different for each patient. This dilemma is common in weight loss management and in determining if a patient needs surgery.
Bariatric surgery is a term that encompasses all types of surgery done specifically for obesity. Indications for bariatric surgery vary based on the patient. One factor considered is a patient's body-mass index or BMI. BMI is calculated based on one's weight and height. In general, to be considered obese, your BMI must be over 30. Morbid obesity is defined as obesity plus another related medical condition such as diabetes.
According to the National Institutes of Health (NIH), surgery should be considered as a treatment for patients with a BMI of 40 or greater who tried but failed an adequate exercise and diet program. Surgery is also considered for a BMI of 35 or higher with one or more obesity-related conditions such as high blood pressure, high blood sugar, diabetes, or sleep apnea. The American Society for Metabolic and Bariatric Surgery (ASMBS) as well as the NIH consensus guidelines for the treatment of obesity state that bariatric surgery is the most effective treatment for morbid obesity. There is data that shows the surgery will "pay for itself" in two years, based on the health benefits gained from the procedure. Despite this, many insurers will not cover it, and you may need to still pay out of pocket. Many surgery programs now have "self-pay" options and pricing depends on the procedure.
There are multiple types of bariatric surgery, and ways to perform them. Today, most are "laparoscopic" where surgeons make a few small incisions and place surgical instruments and a camera into the abdomen and watch their surgery on a video screen. Some procedures place a band around the stomach to make the functioning part smaller. Others cut the stomach to make it smaller, and others manipulate both the size of the stomach and the flow through the small intestine in order to restrict the amount you eat and slightly decrease absorption.
So, if you fit the indications for the surgery, what do you do next? First, find a multidisciplinary program that has program coordinators who assist with the process before, during, and after surgery. The programs will help you document any evidence of medically-supervised diets, or prior attempts to lose weight via diet and exercise — both of which insurance companies often ask for. They will also be sure that the surgery is indicated for you. Most major medical centers have websites that discuss their bariatric surgery program.
For help with this article, I worked with Jacob Greenberg, MD — a UW surgeon specializing in minimally invasive and bariatric surgery. He works with the UW Hospital bariatric program, which you can learn more about at www.uwhealth.org/weight-loss-surgery/bariatric-surgery/10410.
Above all, discuss the implications of the surgery with your physicians and family. It is not just a quick fix. It is a lifestyle change, just like all treatments for obesity.
This column provides general health information and is not specific advice intended for any particular individual(s). It is not a professional medical opinion or a diagnosis. Always consult your personal health care provider about your concerns. No ongoing relationship of any sort (including but not limited to any form of professional relationship) is implied or offered by Dr. Gerhart to people submitting questions.
Date Published: 01/17/2012