Insurance Coverage of Pediatric Bariatric Surgery: a Cross-Sectional Analysis of the USA

Purpose Pediatric bariatric surgery is increasingly recognized as a safe and effective option for the management of obesity and obesity-related conditions. However, insurance coverage is a key barrier to accessing these procedures. Criteria are variable and often not evidence-based. In an effort to...

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Bibliographic Details
Published in:Obesity surgery 2022, Vol.32 (1), p.123-132
Main Authors: Knighton, Brooks J., Yusuf, Cynthia T., Ha, Michael, Ngaage, Ledibabari M., Gebran, Selim, Kubicki, Natalia, Kligman, Mark D., Rasko, Yvonne M.
Format: Article
Language:English
Subjects:
Adolescent
Adult
Bariatric Surgery
Child
Cross-Sectional Studies
Gastroesophageal reflux
Gastrointestinal surgery
Humans
Insurance Coverage
Medicine
Medicine & Public Health
Obesity
Obesity, Morbid - surgery
Original Contributions
Pediatrics
Surgery
Teams
Teenagers
Weight control
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Summary:Purpose Pediatric bariatric surgery is increasingly recognized as a safe and effective option for the management of obesity and obesity-related conditions. However, insurance coverage is a key barrier to accessing these procedures. Criteria are variable and often not evidence-based. In an effort to characterize common patterns in insurance coverage, we report coverage criteria for adolescents relative to adults. Materials and Methods We surveyed medical policies of the 50 highest market share health insurance providers in the USA. Private insurer coverage criteria included age, Tanner staging, skeletal maturity, body mass index, procedures covered, medical weight management requirements, co-morbidities, and multidisciplinary team criteria. These were then compared to the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines. Results Two thirds ( n  = 33, 66%) of companies provided inclusion criteria for adolescents. All policies covered RYGB ( n  = 33), most covered sleeve gastrectomy ( n  = 32, 97.0%). Obstructive sleep apnea (OSA) ( n  = 32, 97%), hypertension (HTN) ( n  = 27, 81.8%), and gastroesophageal reflux disease (GERD) ( n  = 11, 33.3%) were the three most commonly cited co-morbidities used as inclusion criteria. Tanner staging or skeletal maturity were most commonly used ( n  = 10, 30.3%). Similarly, twenty (60.6%) insurers required medical weight management programs. Multi-disciplinary teams were required by 81.8% of adolescent policies ( n  = 27) as described by the ASMBS. Seventeen (51.5%) policies defined providers for these teams, and 10 (30.3%) provided other defined criteria. Conclusion Contrary to ASMBS guidelines, companies commonly require Tanner staging and/or skeletal maturity criteria as well as participation in medical weight management programs. Also, multi-disciplinary team are frequently required but not well defined. Graphical abstract
ISSN:0960-8923
1708-0428
1708-0428
DOI:10.1007/s11695-021-05744-9