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INSURANCE COVERAGE FOR GASTRIC
BYPASS
SURGERY
Obesity
and Health Insurance
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
appetite control,
weight control, and
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.
The Pharmacy Benefit
Management Institute reports that appetite
suppression products have been excluded by more
than 80% of employers, according to a sample of
375 companies representing almost 12 million
beneficiaries in 1998. This represented the
third straight year that the exclusion rate was
above 80%. Decisions to exclude these products
increased after the 1996 introduction of ReduxTM
by Wyeth-Ayerst.
Legislation to require health
insurance coverage for weight loss programs is
under consideration in at least five states -
Georgia, Hawaii, Maryland, Montana and Virginia.
The AOA’s brochure,
Weight Management and Health Insurance,
offers suggestions on requesting reimbursement
for weight loss treatment from health insurance
companies or employers, and appealing denials
for coverage.
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
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
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.
Supplemented Fasting
On supplemented fasting, the Medicare Coverage
Manual states that:
-
Supplemented fasting is a
type of very low calorie weight reduction
regimen used to achieve rapid weight loss. The
reduced calorie intake is supplemented by a
mixture of protein, carbohydrates, vitamins
and minerals.
Serious questions exist
about the safety of prolonged adherence for
two months or more to a very low calorie
weight reduction regimen as a general
treatment for obesity, because of instances of
cardiopathology and sudden death, as well as
possible loss of body protein. Therefore,
supplemented fasting is not covered as a
general treatment for obesity.
In cases where weight loss
is necessary before surgery in order to
ameliorate the complications posed by obesity
when it coexists with pathological conditions
such as cardiac and respiratory diseases,
diabetes or hypertension (and other more
conservative techniques to achieve this end
are not regarded as appropriate), supplemented
fasting with adequate monitoring of the
patient are covered under Medicare on a
case-by-case basis, as determined by your
medical consultant.
The risks associated with
the achievement of rapid weight loss must be
carefully balanced against the risk posed by
the condition requiring surgical treatment.
Gastric Bypass Surgery
Surgery for the treatment of obesity is covered
on a limited basis. According to the Medicare
Coverage Manual:
-
it is medically
appropriate for the individual to have such
surgery.
-
the surgery is to correct
an illness, which caused the obesity or was
aggravated by the obesity.
Home l
Gastric Bypass Surgery
l
Gastric Bypass Overview
l
Benefits of Surgery
Surgery Candidates
l
Gastric Bypass Risks
l
After
Gastric Bypass l
Gastric Bypass Insurance
Before and
After Photos l
Physicians &
Surgeons
l
Understanding
Obesity l
Obesity Statistics
Childhood Obesity
l
Obesity Health Risks
l
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