Guidelines for coverage of bariatric surgery
October 18, 2024
With the huge interest in GLP-1 medications for obesity, it’s easy to overlook the important role bariatric surgery continues to play in treating obesity. Bariatric surgery is highly effective; those having gastric sleeve or traditional bypass (Roux en Y) generally lose 70-80% of their excess weight within a year and maintain a substantial portion of that weight loss over the long term. The cost of bariatric surgery, about $25,000, is substantially less than the cost of ongoing treatment with GLP-1 medications.
Bariatric surgery is associated with improved metabolic function, decreased cardiovascular disease, decreased obesity-related cancers, and improved life expectancy.
Nonetheless, less than 1% of those who are eligible for this surgery have had it. While bariatric surgery performed at centers with multidisciplinary teams has a low rate of complications, those who have the surgery need to commit to altering their eating patterns. Many with obesity live far away from high-volume bariatric surgery centers, and many insurance plans have historically excluded bariatric surgery.
The WTW 2025 Best Practices in Healthcare Survey shows that 67% of employers (and 73% of employers with over 1,000 employees) now cover bariatric surgery. Those that do not cover bariatric surgery often have plans designed years ago, when obesity was considered a lifestyle disease rather than a metabolic illness.
Implications for employers:
For employers reviewing their coverage of bariatric surgery, here are some considerations. These are based on the 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) guidelines.
The ASBMS recommends coverage in adults with BMI >35, or >30 if the individual has metabolic complications (like diabetes or hypertension).
These guidelines recommend coverage for BMI levels >27.5 for those of Asian descent. That’s because those of Asian descent are likely to be more “round,” and adipose tissue adjacent to abdominal organs causes more metabolic damage.
The ASBMS, in conjunction with the American Academy of Pediatrics, also recommends consideration of bariatric surgery in children with BMI >40 (or >35 with metabolic complications), or adolescents with weight more than 140% of 95th percentile for age and gender (or 120% of 95th percentile if the child has metabolic complications)
There is no need for psychiatric evaluation prior to bariatric surgery, and there is no evidence that such evaluations lead to better outcomes.
Many plan designs limit members to a single bariatric surgery in a lifetime. I recommend against such a limit, as some with very severe obesity require staged operations, and some with a failed past lap band surgery require a second surgery.
Some plan designs include a maximum spending allowance for this surgery, treating bariatric surgery differently than other medically necessary procedures. A Center of Excellence is likely a better approach, since the plan is in a better position to negotiate case rates than individual patients.
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Illustration by Dall-E