|
Most insurance companies
will pay for gastric
bypass surgery procedures
that are medically
necessary. Morbid obesity
is a life threatening
disease and it is
normally covered.
Aetna Insurance is now
asking for the patients
entire medical work-up
along with the
pre-authorization request
as well as documented
weight loss attempts
supervised by a physician
for the last 2 years.
They also want documented
weight history for the
last 5 years.
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
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
O besity,
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
-
In
1990, Congress
enacted the Omnibus
Budget
Reconciliation Act (OBRA),
which funds state
programs to provide
pharmaceutical
products to Medicaid
recipients.
-
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
-
The
Medicare Coverage
Manual defines
obesity and the
justification for
certain treatment
coverage by stating
that:
-
Obesity itself
cannot be
considered an
illness. The
immediate cause
is a caloric
intake, which
is persistently
higher than
caloric output.
-
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.
Gastric Bypass Surgery
Gastric bypass 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.
Payment information
Contact Weight Loss
Surgery Centers to find
our your coverage options
for gastric bypass
surgery.
Contact
Us
Home
l
Bariatric Surgeons
l
Gastric Bypass Surgery
l
LAP BAND Surgery
Obesity Health Risks
l
Surgery Risks
l
Surgery Candidates
l
Contact Us
Copyright 2004-2006© Sienna
Design Group. All Rights
Reserved.
Website Design by SDG
|
