New York Insurers Release Weight Control Surgery Guidelines

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New York state health insurers have worked with top surgeons to develop guidelines for evaluating requests for weight control surgery coverage.

Members of a review team organized by the New York Health Plan Association, Albany, N.Y., say covering the surgery sometimes makes sense.

Although bariatric surgery, or moves to reduce a patients stomach capacity, can cause serious complications, it “can improve most obesity-related conditions, reduce the risk of premature death and improve quality of life for patients who are morbidly obese,” says Dr. Susan Beane, a review team member who is medical director of Affinity Health Plan, New York.

Plans should consider covering bariatric surgery for a candidate aged 18 to 65 who has a body mass index over 40 or for a patient with a BMI over 35 and obesity-related health problems, according to the NYHPA guidelines.

For a man of average height, a BMI over 40 means that the man is about 100 pounds over the average weight.

Candidates also should stop smoking, overcome any other substance abuse problems and show that they have failed at efforts to diet, and plans should encourage candidates to use high-volume bariatric surgery centers, the NYHPA review team says.

The review team included 12 high-volume bariatric surgeons and 9 health plan medical directors.

The NYHPA guidelines appear to be the first well-publicized state health plan association bariatric surgery guidelines, according to Dr. Alan Muney, chief medical officer at Oxford Health Plans Inc., Trumbull, Conn.

“Its very important, whenever possible, for health plans to get together,” Muney says.

Consensus guidelines can improve the quality of care and help doctors understand plans coverage decisions, Muney says.

Although the NYHPA guidelines are an informal source of information, not a set of formal coverage guidelines, they could influence the development of guidelines in other states.

U.S. surgeons will perform 144,000 bariatric procedures this year, up from 25,800 in 1998. That compares with an annual volume of 80,000 for eye operations and 303,000 for appendectomies.

In the real world, the topic of bariatric surgery benefits “does actually come up with clients,” says Kirby Nielsen, a Westerville, Ohio, agent. He gets more questions about bariatric surgery benefits than about coverage for any other type of surgery, including bone marrow transplants.

Nielsen says offering easy access to bariatric surgery benefits could send consumers the wrong message about responsibility for their health, but he notes that one of his own friends has benefited greatly from undergoing bariatric surgery.


Reproduced from National Underwriter Edition, June 4, 2004. Copyright 2004 by The National Underwriter Company in the serial publication. All rights reserved.Copyright in this article as an independent work may be held by the author.