Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies
Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies
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DOI：
10.1007/s11695-019-04243-2
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发表时间：
2020-02-01
期刊：
影响因子：
2.9
通讯作者：
Rasko, Yvonne M.
中科院分区：
文献类型：
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作者：
Gebran, Selim G.;Knighton, Brooks;Rasko, Yvonne M.
背景减肥手术在全国范围内仍未得到充分利用，保险公司报销是获得这些手术的一个重要决定因素。我们调查了私营保险公司制定的减肥手术保险标准的现状。方法我们调查了美国市场占有率最高的健康保险提供商的医疗保单。ASMBS指南和CMS减肥前评估标准被用来收集私营保险公司的覆盖标准，其中包括覆盖的程序、年龄、BMI、合并症、医疗体重管理计划(MWM)、心理社会评估和卓越中心的指定。结果61家公司(95%)已经确定了预先授权政策。所有保单均投保RYGB，57份(93%)投保法援署或秘书长。程序的覆盖范围仅限于43%的保单(n=26)的卓越中心。共有92%的保单要求体重指数在40或以上或35或以上，并有共同发病率；然而，在涵盖青少年的保单中，43%(n=23)的青少年(n=36)的BMI要求较高，为40或以上，并有共同发病率。大多数政策需要额外评估(MWM 87%，心理社会评估75%)。79%(n=48)的保单涵盖了修订程序。因减肥失败而进行第二次减肥手术的报销频率较低(n=41，67%)。结论大多数私营保险公司在获得批准之前仍然需要有监督的医疗体重管理计划，而且大多数不会涵盖青少年减肥手术，除非满足某些标准，而目前的证据并不支持这些标准。
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.