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Cited by 57Bariatric Surgery and OutcomesBody Contouring and SurgeryObesity and Health Practices

Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies

Gebran, Selim G., Knighton, Brooks, Ngaage, Ledibabari M., Rose, John A., Grant, Michael P., Liang, Fan, Nam, Arthur J., Kavic, Stephen M. +2 more·2020·Obesity Surgery
DOI 10.1007/s11695-019-04243-2
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Abstract

Background Bariatric surgery remains underutilized at a national scale, and insurance company reimbursement is an important determinant of access to these procedures. We examined the current state of coverage criteria for bariatric surgery set by private insurance companies. Methods We surveyed medical policies of the 64 highest market share health insurance providers in the USA. ASMBS guidelines and the CMS criteria for pre-bariatric evaluation were used to collect private insurer coverage criteria, which included procedures covered, age, BMI, co-morbidities, medical weight management program (MWM), psychosocial evaluation, and a center of excellence designation. We derive a comprehensive checklist for pre-bariatric patient evaluation. Results Sixty-one companies (95%) had defined pre-authorization policies. All policies covered the RYGB, and 57 (93%) covered the LAGB or the SG. Procedures had coverage limited to center of excellence in 43% of policies (n = 26). A total of 92% required a BMI of 40 or above or of 35 or above with a co-morbidity; however, 43% (n = 23) of policies covering adolescents (n = 36) had a higher BMI requirement of 40 or above with a co-morbidity. Additional evaluation was required in the majority of policies (MWM 87%, psychosocial evaluation 75%). Revision procedures were covered in 79% (n = 48) of policies. Reimbursement of a second bariatric procedure for failure of weight loss was less frequently found (n = 41, 67%). Conclusions A majority of private insurers still require a supervised medical weight management program prior to approval, and most will not cover adolescent bariatric surgery unless certain criteria, which are not supported by current evidence, are met.

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  • It is common practice to require the presence of another disease (so-called obesity plus criteria) for indication to and coverage of obesity treatment.

    “It is common practice to require the presence of another disease (so-called obesity plus criteria) for indication to and coverage of obesity treatment.”

    From Definition and diagnostic criteria of clinical obesity (2025) · cites this paper as [24]

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Authors
Gebran, S. G., Knighton, B., Ngaage, L. M., Rose, J. A., Grant, M. P., Liang, F., Nam, A. J., Kavic, S. M., Kligman, M. D., & Rasko, Y. M.
Affiliations
  • University of Maryland, Baltimore (US)
  • Johns Hopkins University (US)
Corresponding author
Rasko, Yvonne M.
ORCID
Venue
Obesity Surgery
Publisher
Springer Science and Business Media LLC
Published
2019-11-20
Volume
30
Issue
2
Pages
707-713
ISSN
  • 0960-8923 (ISSN-L)
  • 1708-0428
DOI
10.1007/s11695-019-04243-2
OpenAlex
W2991475768
Cited by
56
References
39
Citations by year
2026: 7 · 2025: 7 · 2024: 13 · 2023: 7 · 2022: 11 · 2021: 8 · 2020: 3
FWCI
5.30
Type
journal article
Language
en
Open access
closed
Licence
Locations
  • Obesity Surgery (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Bariatric Surgery and Outcomes
  • Health Sciences › Medicine › Surgery › Body Contouring and Surgery
  • Health Sciences › Health Professions › Pharmacy › Obesity and Health Practices
Keywords
bariatric surgery
MeSH terms
Adolescent, Adult, Age Factors, Aged, Female, Health Policy, Humans, Insurance, Health, Male, Middle Aged, Obesity, Morbid, Surveys and Questionnaires, Reoperation, United States, Weight Loss, Comorbidity, Health Care Costs, Insurance Coverage, Mandatory Programs, Bariatric Surgery, Young Adult, Weight Reduction Programs, Pediatric Obesity

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