Medical Director’s Notes: Assessing the Clinical Efficacy of Gastric Bypass Surgery

This October MSNBC reported on a phenomenon that has recently come to light in the bariatric surgical arena. The report discussed a young lady who gained weight to meet the BMI (body mass index) requirement so her weight loss surgery would be covered by her health insurance plan. The woman was finally enrolled in a clinical trial and had her surgery covered by the clinical trial. This clinical trial, in fact, was one of the studies the Food and Drug Administration (FDA) relied on in its decision to lower the BMI requirement for lap band surgery. FDA modified its recommendation and lowered the BMI to 30 when associated with a weight-related illness. Previously, the lap band “stomach-shrinking device” was reserved for patients who were at least 100 pounds overweight or had a BMI of at least 40, or a BMI of at least 35 with other co-morbidities such as heart disease.

Although bariatric surgery has been shown to be of great value to the severely obese who have tried and failed numerous non-surgical methods, surgery still would not constitute the best practice for the management of mild to moderate obesity. Even the FDA’s panel vote was not unanimous to lower the lap band BMI to 30, as the procedure profoundly changes the individual’s way of eating and this is a surgical procedure with all of the risk inherent of surgery.

The phenomena of eating to gain weight should be viewed as a psychological disqualifier of weight-loss surgery. By taking this approach, the patient makes it obvious they do not understand their disorder. They also do not understand that the way they eat and what they eat after the surgery will need to change. Therefore, for the surgery to be a success, patients must commit to changing their eating habits and activities. This is not a “get thin quick” plan, but rather a course of action that should only be undertaken when everything else has failed. Individuals who would gain weight just to get coverage are not good candidates for the surgery as the post-surgical likelihood of these individuals following their doctor’s instructions and diet plans are very low. In fact, recent articles indicate surgeons have cancelled the surgery due to the member’s deceptive activity (e.g., gaining weight to gain insurance coverage).

To that end, health plans continue to encourage their members to exhaust all the possible alternate methods of weight loss before considering surgery. This is not an attempt by most insurers to simply avoid the cost of the surgery – as the benefit for those who need it makes this a very cost-effective procedure for both the insurer and employer – but rather because surgery is the last and least desirable option. One’s health (psychological and physical) will be much improved if the weight loss is achieved through modification of diet and lifestyle changes, including exercise.

Insurers place restrictions on coverage of different services and offer coverage only when it is a medical necessity. This is to insure quality of care and the offering of an affordable insurance product to members. Therefore, the restrictions on surgical coverage for bariatric surgeries serve two purposes:

1. Insure that members who need the surgery are able to get the procedure and that money is not wasted when it is not a medical necessity; and
2. Use financial incentives to encourage members who do not need the surgery, and who are clinically better served with lifestyle changes, to undertake these changes.

Using National Institutes of Health guidelines and current consensus statements from the specialty boards, AMM has developed the following coverage recommendations:

1. BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with high-risk, co-morbid conditions or obesity-induced physical problems interfering with lifestyle.
2. Failure of nonsurgical weight loss efforts to include physician-supervised weight loss programs within the last 12 months. Therefore, the member has to have exceeded the BMI for at least one year prior to the surgery despite a physician-supervised weight loss program.
3. Absence of contraindications (medical and psychological). This would exclude anyone who purposely puts on weight for the sake of gaining coverage for the procedure as this is a relatively psychological contraindication.
4. Well-informed, compliant, motivated patient. The act of purposefully putting on weight for the sake of gaining coverage would be incongruent with being “well-informed, compliant, motivated” and therefore the member would fail this requirement.