In December, National Public Radio (NPR) ran an article Insurers Often Don’t Pay For Teen Weight-Loss Surgery describing the difficult situation facing adolescents in need of weight loss surgery. For adults, standard bariatric procedures are usually covered, whether by employers, Medicaid, or some other form of insurance; in teens, however, coverage is not so easily obtained. We asked Jeffrey L. Zitsman, MD, Director of the Center for Adolescent Bariatric Surgery at NewYork-Presbyterian Morgan Stanley Children’s Hospital/Columbia University Medical Center, to explain what the situation was like here in New York.
According to Dr. Zitsman, only two institutions in the New York area have been approved by the FDA to offer adolescent bariatric surgery as part of limited studies investigating laparoscopic gastric banding in patients under age 18. If patients qualify for surgery according to the study criteria, they can obtain laparoscopic banding at these select institutions. Although the surgery is permitted in adolescents as part of the study, payment is still required. Yet Medicaid plans and most private insurance policies are not consistent in their coverage, nor are they always eager to cover costly surgical procedures, even despite the clear health – and financial – benefits associated with significant weight loss.
As a result, Dr. Zitsman has had to appeal to most of his patients’ insurance companies in one form or another, to a greater or lesser degree, to secure coverage for treatment. “Even for patients who have private insurance, I often have to fight for coverage. In some cases, a patient’s insurance plan does not cover the surgery, and he or she changes to another plan that does.”
To illustrate the current situation, Dr. Zitsman summarized the results of a period in which he had 105 adolescent patients in need of bariatric surgery. After providing the insurers with the results of relevant medical tests and specialists’ opinions indicating a need for bariatric surgery, less than half (44 of the 105) were approved on initial application. Some insurance companies requested additional information, such as additional testing or a second physician letter; after responding to such requests, 32 more patients were approved for surgery. Seventy-six of the 105, then, eventually received coverage after months of negotiation.
For the remaining 29 patients, it was necessary to be even more aggressive. Dr. Zitsman wrote additional appeal letters for 10 patients, 16 required peer-to-peer calls, and two patients hired lawyers to challenge their insurance companies’ decisions. The result of all this extra effort: 24 more approvals. And of the five remaining patients, one paid for the surgery entirely out-of-pocket; the others, denied coverage, were unable to get surgery at all.
According to Dr. Zitsman, that sample is representative of the situation in adolescent bariatric surgery more broadly. The field itself is changing — since 2010, procedures such as gastric sleeve resections have become increasingly prevalent — but for the most part, the difficulties of obtaining coverage for adolescents remain about the same.
The FDA may soon determine whether to approve laparoscopic gastric banding for patients under 18. Based on his experience with adolescent patients, Dr. Zitsman believes that the procedure should be made available as standard treatment for appropriate patients. He also states that regardless of a surgical procedure, weight loss requires making good food choices, limiting quantities, and balancing what one needs with what one takes in. Some people, he notes, are not able to do that. His team works closely with behavioral researchers at the New York State Psychiatric Institute who are currently doing in-depth evaluations and research in its eating behaviors laboratory.
Dr. Zitsman has directed the multidisciplinary program for adolescent bariatric surgery at NewYork-Presbyterian/Columbia since 2005. For more information about the program, please visit the Center for Metabolic and Weight Loss Surgery.