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More than half of teens seeking bariatric surgery initially denied coverage
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Adolescents who seek weight loss surgery are more often denied insurance coverage than adults, with fewer than half of appropriate surgical candidates receiving approval on the first request, according to recent findings.
In the retrospective review, researchers evaluated clinical data of 57 adolescents (74% female) who were clinically eligible for weight loss surgery. The cases identified for inclusion were seen at one of five bariatric surgery centers, were ≤17 years and had insurance that covered weight loss surgery. Patients were also required to have sent a letter of medical necessity to an insurance company between Jan. 1, 2009 and Jan. 1, 2011.
The researchers reviewed the patients’ records and culled the following data: age, BMI, gender, race, presence of comorbidities, type of insurance coverage, type of surgery requested (Roux-en-Y gastric bypass [RYGB] or vertical sleeve gastrectomy [VSG]), date of letter of medical necessity submission, date of approval, dates and reasons for coverage denial, dates and outcomes of appeals and date of surgery.
The researchers found that only 47% of patients were granted approval of their initial letter of medical necessity submission. Among those denied, the specific reasons for original denial were as follows: being <18 years (73%), type of procedure requested (27% all of which were VSG), insufficient duration of medically-supervised weight loss program as assessed by the insurer (10%), lack of medical necessity as determined by the insurer (10%) and psychological concern (10%).
Subsequently, 80% of these requests were approved on appeal and 11% were never approved.
“In conclusion, the results of this study suggest that adolescents seeking [weight loss surgery] have higher denial rates than comparable reports in adults,” the researchers wrote. “Patient age, rather than medical necessity, appeared to be the primary reason for denial. Ongoing research efforts will better define the effectiveness and safety of surgical interventions for adolescent severe obesity, which should permit data-driven decisions and policy about access to care in the future.”
Disclosure: See the full study for a complete list of the researchers’ relevant financial disclosures.
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