During the past 20 years, there has been a dramatic increase in obesity in the United States. Thirty states have obesity rates of more than 20 percent. Currently, more than 44 million Americans are considered obese, the result of our fast-food life style and lack of exercise.
As a result, more obese Americans are turning to bariatric surgery. In 1995, just 20,000 weight-loss operations were performed in the United States. Last year, physicians performed 103,000 bariatric surgeries, an increase of more than 500 percent. The projection for 2005 rises to 144,000.
These surgeries are in the range of $30,000 each and if complications arise, even more. Even though some health insurance groups do not include this surgery in their plan language, requests for independent medical reviews regarding bariatric surgery have surged over the past year.
Most of these reviews hinge on what’s considered medically necessary or optional when it comes to bariatric surgery. As a claims manager, there are several issues to consider when making a decision about a patient’s claim for bariatric surgery:
Is the person suffering from morbid obesity? (The term morbid obesity refers to patients who are 50-100% or 100 pounds above their ideal body weight. )
Has the patient failed one or more non-surgical multi-component weight loss programs? (Was this an evidence-based, integrated weight loss program — such as the one offered by the Ornish Program — that has sustainable, reproducible results? )
Does the patient have a medical illness related to obesity and is he/she willing to participate in a pre-surgery weight loss effort to improve the success of surgery? (Even a somewhat slimmer patient has reduced cardiac risk. )
Can the patient make the lifestyle adjustment necessary to sustain weight loss? (Many of the dietary limitations are more severe than those needed to lose weight in the first place. )
Only by answering these questions, or using the expertise of your IRO, can you make an informed decision as to whether the claim is medically necessary or considered a cosmetic procedure.