Despite the evidence supporting the safety, clinical benefits and cost-effectiveness of metabolic/bariatric surgery (MBS), uptake of these procedures in eligible patients remains low. Studies have documented significant disparities between the general population with severe obesity and the subset that have access to an/or receive MBS. Insurance coverage policies may be one reason why medically eligible patients are unable to receive MBS. This is the largest review of commercial insurance payors to evaluate coverage policies for MBS.
To evaluate commercial plan's MBS coverage and associated access requirements in the United States.Methods:Bariatric policies, reviewed as of March 2020, by insurer for each specific state were analyzed for coverage and plan details.
A total of 207 policies were reviewed covering 172,750,033 lives. Just over half (59.4%) of reviewed policies covered MBS. Of the plans with coverage over half (50.4%) required pre-operative weight loss. Regarding pre-operative regimens, 39.8% required a 3-12 month requirement, with 6 months being the most common (30.9%). Adolescent coverage is included in 54.7% of plans. Very few (14.6%) plans cover Low BMI (30-35) with Type II DM. The majority of plans (73.2%) covered revision procedures.
Varying policies and requirements may lead to patients who are medically eligible being unable to obtain MBS. This study will allow identification of coverage policies with excessive requirements to target advocacy efforts. Surgeons will be able to identify how their regional plans compare.