Top 25 US insurers fail to provide coverage for intragastric balloon, endoscopic sleeve
Click Here to Manage Email Alerts
Key takeaways:
- None of the largest U.S. insurers provide coverage for intragastric balloon or endoscopic sleeve gastroplasty.
- Endoscopic revisions for prior bariatric surgeries were also not covered.
PHILADELPHIA — None of the top 25 insurers in the United States offer explicit policy coverage for primary or revisional endoscopic bariatric therapies, according to data presented at the ACG Annual Scientific Meeting.
“While lifestyle interventions have yielded transient and modest effect sizes, surgical interventions [for obesity] have produced the largest effects; however, surgeries are associated with significant procedural complications, significant perceived risk and costs,” Sagar Shah, MD, from the David Geffen School of Medicine at UCLA, told attendees. “There is a growing body of evidence supporting the safety and efficacy of these endobariatric therapies, but there seems to be discord between that evidence base and insurance coverage for these procedures.
“Anecdotally, our patients have communicated experiencing significant difficulty navigating the insurance system for costs related to endobariatric therapies, and physicians face many of these same challenges interacting with insurance companies.”
To assess insurance coverage patterns for endoscopic bariatric therapies, Shah and colleagues performed an internet search for policies from the 25 largest health insurers in the U.S., with a focus on four procedures: endoscopic sleeve gastroplasty, intragastric balloon, transoral outlet reduction and sleeve gastrectomy revision.
Additionally, the researchers examined criteria such as BMI thresholds, preoperative medical and mental health evaluations, age restrictions, documented surgical complications and obesity-related comorbidities.
The researchers reported that no insurance policy documentation could be obtained for two of the insurers. Among the remaining 23 insurers with publicly available policies, none included primary endoscopic bariatric therapies in their coverage, and only 20 covered revisional endoscopic bariatric therapies (P < .001).
Revisions for treatment failure — defined as failure to achieve and/or maintain weight loss — were covered by 16 of the top insurers, yet seven insurers either explicitly did not cover or failed to disclose its coverage for treatment failure revisions.
Shah and colleagues reported that coverage polices for revisional procedures following treatment failure were “inconsistent and often unclear”: 11 insurers provided numeric criteria for inadequate weight loss, but five insurers either did not clearly define treatment failure in their policy or determined failure on a case-by-case basis.
“Specific criteria for the coverage of bariatric procedures are often not provided, and determining whether or not a patient qualifies for coverage requires significant effort on both the part of the patient and physicians,” Shah said. “Even when criteria are specified, they are far from uniform.”
All 16 insurers that covered treatment failure revisions covered only surgical revisions vs. endoscopic revisions of previous bariatric surgeries, such as transoral outlet reduction and sleeve gastrectomy revision. Moreover, 10 insurers failed to mention transoral outlet reduction in their covered revisional procedures, while the remaining 13 insurers classified the procedure investigational.
“In 15 cases, [sleeve gastrectomy revision] was deemed investigational or unproven, and in eight cases, these procedures simply weren’t mentioned in the policy documentation,” Shah said.
Shah noted that, based on the insurers’ published information, overall coverage for endoscopic bariatric therapies is poor and needs to better align with current evidence if providers are expected to curb rising obesity rates.
“The results of our study demonstrate that the 25 largest insurers in the United States don’t explicitly provide coverage for endobariatric therapies, neither as primary nor as revisional therapies,” Shah said. “While this is just a snapshot of a rapidly evolving field in 2024, it flies in the face of the fact that, by some estimates, we are performing 5,000 to 6,000 [endoscopic sleeve gastroplasties] in this country annually.”
Collapse
Shah S, et al. Insurance coverage for endoscopic bariatric therapy in 2024: Analyses of the top insurers in the U.S. Presented at: ACG Annual Scientific Meeting; Oct. 25-30, 2024; Philadelphia (hybrid meeting).
Read more about
Click Here to Manage Email Alerts