Insurance coverage

New guidelines expand eligibility for bariatric surgery. Will insurance coverage follow?

Two groups of bariatric surgeons have revised bariatric surgery guidelines for the first time in more than 30 years, saying previous standards are outdated and inadequate to deal with rising levels of obesity in the United States.

new standards, published early Fridaywill significantly increase the number of people eligible for operations.

Weight-loss surgery has become dramatically safer in recent decades and has reversed or improved dozens of weight-related illnesses, but guidelines last established in 1991 have not been implemented. updated to reflect improvements. That’s why the American Society for Metabolic and Bariatric Surgery and the International Federation for Surgery for Obesity and Metabolic Disorders, which represents 72 countries, decided to make the new recommendations.

The old guidelines were “trapped in the past,” said Dr. Shanu Kothari, outgoing president of the American Society for Metabolic and Bariatric Surgery. “We’ve made huge strides in the fields of metabolic and bariatric surgery over three decades, so we think it’s time to update them.”

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The new guidelines lower the weight limit to qualify for surgery and remove the requirement that all but the heaviest people must have a medical condition resulting from their obesity. Children and adolescents are also now eligible for surgery.

Kothari said he hopes insurance companies will update their coverage to comply with the new standards. Other medical organizations like the American Heart Association and the American Diabetes Association update their treatment guidelines every year or two, and insurance coverage generally reflects these changes.

Insurance companies deny weight loss surgery to children when they meet all the criteria for adults.

Confusion over who qualifies for surgery

Today, many patients and their doctors do not know who is eligible for surgery and who is not.

“It’s a mess,” said Dr Ali Aminian, who helped draft the new guidelines.

At the last count, before the pandemic, 42% of Americans met the definition of obesity and about 10% suffer from diabetes, which increases the risk of a wide range of medical problems, from heart disease to amputations. Over 200 diseases have been linked to being overweight.

Weight-loss surgeries that previously required five to seven days of hospitalization and several months of recovery are now performed with keyhole incisions, often with robotic assistance, Aminian said.

Patients routinely go home the next day and can resume their normal lives, without post-surgical pain, in two to three days, he said. Surgery-related mortality rates have been reduced by 20 to 30, from 2 or 3 in 100 patients to around 1 in 1,000.

Changing the guidelines won’t remove the lack of public awareness, stigma or fear around bariatric surgery or ensuring insurance coverage, but it will remove a barrier to care, said Aminian, who runs the Bariatric and Metabolic Institute at the Cleveland Clinic.

“Even if you’ve simply failed conventional means, regardless of your comorbidity status, we believe surgery should be considered,” said Kothari, also president of surgery at Prisma Health in Greenville, South Carolina.

New guidelines still based on BMI

The new guidelines, like the old ones, are based on body mass index, a measure of weight relative to height.

Previously, to be eligible for surgery, patients had to have a BMI of at least 40 or a BMI of 35 or more and at least one obesity-related medical condition such as hypertension or heart disease. Diabetes was not included, although surgery has since been shown to significantly alter metabolism, often rapidly reversing diabetes.

Under the new guidelines, anyone with a BMI over 35 should be considered for surgery, whether or not they have any medical conditions, according to the new guidelines, as well as people with a BMI over 30, the definition obesity official, if they have not been able to achieve significant or sustained weight loss.

For people of Asian descent, surgeons lowered the BMI requirement for surgery to 27.5 because they often have weight-related health issues starting at lower body mass.

Dr. Ali Aminian, bariatric surgeon at the Cleveland Clinic

Dr. Ali Aminian, bariatric surgeon at the Cleveland Clinic

Children and teenagers suffering from severe obesity are also eligible for surgery according to the new criteria. They have generally been excluded from precedents due to a lack of data.

Weight-related illnesses are easier to reverse if treated during adolescence, Aminian said.

“We have a lot of data to support that the outcomes of children who had surgery were much better than the outcomes of patients who had surgery for their obesity in their 40s and 50s,” he said. “If we wait a long time, some of these consequences of obesity are not reversible.”

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Dr. Fatima Cody Stanford, a weight loss specialist at Massachusetts General Hospital, said she wishes surgeons had stopped using BMI as a determining factor for surgery.

“I hate BMI,” she said, noting that it was originally developed as a standard for 19th-century Belgian soldiers and is irrelevant to today’s diverse American population. . “It’s an arbitrary thing. It doesn’t define his health.”

Dr Fatima Cody Stanford

Dr Fatima Cody Stanford

Instead, she said, she would prefer to see a surgery decision based on real health metrics, such as high blood sugar levels, signs of inflammation, high cholesterol and hepatic steatosis. She’s seen people with a BMI of 22 do poorly by those standards, she said, and those with a BMI well over 30 who are healthy.

Her surgery experience was mixed, Stanford said.

She had a patient whose diabetes had been out of control for years, even though he was following doctors’ instructions to the letter. The surgery completely reversed his diabetes.

But many others have had surgery and years later their weight is going back, along with hormonal issues, as the body struggles with weight loss. They benefit from medication, she said, and might have been able to manage on their own with medication.

Gaining weight back after surgery can affect a person’s self-esteem, she said.

Barriers remain

Inadequate medical training and lack of insurance coverage remain a huge barrier to weight loss, whether it’s surgery, drugs or both, Stanford said.

Doctors don’t routinely teach how to help patients lose weight, although more than 100 million Americans struggle with their weight. Her practice is so busy that she isn’t accepting new patients, and the Massachusetts General Weight Loss Center has 4,000 people on its waiting list.

Health coverage for obesity is patchy across the country, but Medicare and insurers rarely cover obesity-related treatment or surgery unless the person also has serious weight-related health issues. In Massachusetts, for example, Medicare covers surgery but not drugs, while leading health plans cover both, Stanford said.

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It’s ironic, Kothari said, that Veterans Administration data helped establish the effectiveness of the surgery, but the VA doesn’t cover the cost of obesity surgery.

Historically, he says, coverage was denied because the inability to lose weight was seen as a matter of willpower, but decades of research show instead that it is driven by biology.

“We have a lot of data to show that obesity is a disease and should be treated as such,” Kothari said. The goal of the new surgical guidelines “is to improve access to deserving patients based on contemporary evidence and…to impact and change coverage policies.”

Contact Karen Weintraub at [email protected]

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This article originally appeared on USA TODAY: Bariatric surgery qualifications may change under new guidelines