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Insurance Coverage of Pediatric Bariatric Surgery: a Cross-Sectional Analysis of the USA

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Abstract

Purpose

Pediatric bariatric surgery is increasingly recognized as a safe and effective option for the management of obesity and obesity-related conditions. However, insurance coverage is a key barrier to accessing these procedures. Criteria are variable and often not evidence-based. In an effort to characterize common patterns in insurance coverage, we report coverage criteria for adolescents relative to adults.

Materials and Methods

We surveyed medical policies of the 50 highest market share health insurance providers in the USA. Private insurer coverage criteria included age, Tanner staging, skeletal maturity, body mass index, procedures covered, medical weight management requirements, co-morbidities, and multidisciplinary team criteria. These were then compared to the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines.

Results

Two thirds (n = 33, 66%) of companies provided inclusion criteria for adolescents. All policies covered RYGB (n = 33), most covered sleeve gastrectomy (n = 32, 97.0%). Obstructive sleep apnea (OSA) (n = 32, 97%), hypertension (HTN) (n = 27, 81.8%), and gastroesophageal reflux disease (GERD) (n = 11, 33.3%) were the three most commonly cited co-morbidities used as inclusion criteria. Tanner staging or skeletal maturity were most commonly used (n = 10, 30.3%). Similarly, twenty (60.6%) insurers required medical weight management programs. Multi-disciplinary teams were required by 81.8% of adolescent policies (n = 27) as described by the ASMBS. Seventeen (51.5%) policies defined providers for these teams, and 10 (30.3%) provided other defined criteria.

Conclusion

Contrary to ASMBS guidelines, companies commonly require Tanner staging and/or skeletal maturity criteria as well as participation in medical weight management programs. Also, multi-disciplinary team are frequently required but not well defined.

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Authors and Affiliations

  1. University of Maryland School of Medicine, Baltimore, 21201, USA

    Brooks J. Knighton & Cynthia T. Yusuf

  2. Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD, 21201, USA

    Michael Ha, Ledibabari M. Ngaage & Yvonne M. Rasko

  3. Division of Plastic Surgery, Department of Surgery, Johns Hopkins Medicine, Baltimore, 21205, USA

    Ledibabari M. Ngaage & Selim Gebran

  4. Department of Surgery, University of Maryland Medical Center, Baltimore, 21201, USA

    Natalia Kubicki & Mark D. Kligman

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  1. Brooks J. Knighton
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Contributions

Brooks J. Knighton: data collection, data analysis, initial manuscript draft, manuscript editing, and final approval of the manuscript. Cynthia T. Yusuf: data collection, manuscript editing, and visual abstract creation. Selim Gebran: data collection. Michael Ha: data validation, supervision, manuscript editing, and final approval of the manuscript. Ledibabari M. Ngaage: study design, manuscript editing, and final approval of the manuscript. Natalia Kubicki: manuscript editing and final approval of the manuscript. Mark D. Kligman: manuscript editing and final approval of the manuscript. Yvonne M. Rasko, MD: study conception, data collection, manuscript editing, and final approval of the manuscript.

Corresponding author

Correspondence to Yvonne M. Rasko.

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This article does not contain any studies with human participants or animals performed by any of the authors.

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Key Points:

Bariatric surgery has been shown to be increasingly efficacious and safe in select adolescents with severe obesity when compared to lifestyle modifications and medical therapy alone.

We have demonstrated that more insurance companies are taking a favorable stance to coverage of these procedures in adolescents.

Many companies use eligibility criteria that is no longer supported by current evidence. These include age limits, skeletal maturity, Tanner staging, BMI cut-offs, medical weight management programs.

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Knighton, B.J., Yusuf, C.T., Ha, M. et al. Insurance Coverage of Pediatric Bariatric Surgery: a Cross-Sectional Analysis of the USA. OBES SURG 32, 123–132 (2022). https://doi.org/10.1007/s11695-021-05744-9

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  • DOI: https://doi.org/10.1007/s11695-021-05744-9

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