Medicare
Medicare has a national policy on surgery for obesity. However, it's general enough that it allows for interpretation. Since Medicare won't pre-authorize LAGB or Gastric Bypass procedures, you can't be sure the procedure will be reimbursed until the claim is processed.
The language states:
"Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS), and LAGB are covered for Medicare beneficiaries who have a body mass index >35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. These procedures are only covered when performed at facilities that are:
(1) Certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or
(2) Certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effect on February 15, 2006).
Private Commercial Payors
Most private insurance plans will cover gastric banding or gastric bypass and sleeve gastrectomy procedures for their members provided that criteria are met. The most commonly accepted guidelines for treatment follow Medicare's NCD and/or those issued by the National Institutes of Health, the Society of Gastrointestinal Endoscopic Surgeons and the American Society for Metabolic and Bariatric Surgery. These include:
- The therapy is medically necessary for the treatment of selected adults (18 years and older) living with morbid obesity.
- The therapy is applied according to the guidelines set forth by the NIH Consensus Conference.
- The patient has a BMI ≥ 40 kg/m2 or a body weight of 100 pounds over ideal body weight, or
- The patient has a BMI ≥ 35 kg/m2 with presence of severe co-morbid conditions such as diabetes, obstructive sleep apnea, hypertension, or coronary heart disease.
- Documented history of failure of medically supervised non-surgical methods of weight reduction such as diet, exercise, and pharmacologic therapy, unless contraindicated.
- Evaluation by a licensed psychologist or psychiatrist documents the absence of significant psychopathology (e.g., active substance abuse, schizophrenia, uncontrolled depression).
- Documentation that obesity interferes with and significantly limits daily functions.
- The patient has no specifically correctable cause for obesity (e.g., endocrine disorder).
Medicaid
Medicaid coverage and payment for LAGB and Gastric Bypass services vary from state to state. Most programs reimburse hospital inpatient services based on a modified version of the Medicare DRG system or case rates and function in a similar way, although with typically lower payment amounts. Other programs may also pay for inpatient services based on per diem rates, all-inclusive payment amounts for each day of inpatient stay. Some states may restrict patient benefits by limiting the number of inpatient hospital days covered or by setting a cap on the dollar amount that will be paid per fiscal year.
