ASMBS: Open Letter to Insurance Companies, Regarding Mandatory Pre-bariatric Surgery Diet Regimens

[DianaCox]

Found this, while looking for something else:
http://asmbs.org/resources/open-let...mandatory-pre-bariatric-surgery-diet-regimens

Published October 2015

To: Insurance Company, Medical Director
From: American Society for Metabolic and Bariatric Surgery (ASMBS)
Re: Mandatory Pre-bariatric Surgery Diet Regimens

It has become increasingly apparent that some bariatric surgery policies are mandating 6-12 month documented preoperative weight loss before approving bariatric surgery. This hurdle is unfortunate for several reasons. There are NO studies documenting the efficacy of this approach. There are several studies which show that a) there is no benefit in terms of long-term weight loss and compliance (1), b) it leads to patients dropping out of the bariatric approach (2), c) there is evidence that this leads to further aggravation of obesity co-morbidities when compared to patients who undergo bariatric surgery (3), and d), most disturbing of all, there is an increased mortality in patients who have been evaluated for bariatric surgery but do not undergo it for insurance denial or other reasons. (4-6) There are also five control, cohort studies which document a decreased mortality in patients who undergo bariatric surgery vs. those who do not. (7-11)

This issue should not be confused with data suggesting that weight loss immediately prior to bariatric surgery may be beneficial by decreasing the size of the liver, making the laparoscopic approach technically less difficult which could be associated with a decreased postoperative morbidity. Immediate preoperative weight loss may also be associated with a better long-term weight loss outcome. (12-15)

We believe that almost all of these patients have had numerous attempts at dietary weight loss, through multiple programs, over many years. It is the position of the American Society for Metabolic and Bariatric Surgery that the requirement for documentation of prolonged preoperative diet efforts before health insurance carrier approval of bariatric surgery services is inappropriate and counterproductive, given the complete absence of a reasonable level of medical evidence to support this practice. Policies such as these that delay, impede, or otherwise interfere with life-saving and cost-effective treatment, which has been proved to be true for bariatric surgery to treat morbid obesity, are unacceptable without supporting evidence.

We would like to take this opportunity to share with you our recent position statement (16) with literature review (attached) and hoping it can be used to update your bariatric surgery coverage policy references and requirements.

Sincerely.

Robin Blackstone, MD, ASMBS President
Jaime Ponce, MD, ASMBS President-Elect, Insurance Committee Chair
John Morton, MD, ASMBS, Access Committee Chair

REFERENCES

1. Janz E, Larson CJ, Methiason MA, Kallies KJ, Kothari SN. Number of weight loss attempts and maximum weight loss before Roux-en-Y laparoscopic gastric bypass surgery are not predictive of postoperative weight loss. Surg Obes Relat Dis 2009;5:208-11.
2. Jamal MK, DeMaria EJ, Johnson JM, et al. Insurance-mandated preoperative counseling does not improve outcome and increases dropout rate in patients considering gastric bypass for morbid obesity. Surg Obes Relat Dis 2006;2:122-7.
3. Harakeh AB, Burkhamer KJ, Kallies KJ, Mathiason MA, Kothari SN. The natural history and metabolic consequences of morbid obesity for patients denied coverage for bariatric surgery. Surg Obes Relat Dis 2010 (in press).
4. MacDonald KG, Jr., Long SD, Swanson MS, et al. The gastric bypass operation reduces the progression and mortality of non-insulin-dependent diabetes mellitus. J Gastrointest Surg 1997;1:213-20.
5. Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: A population-based analysis. J Am Coll Surg 2004;199:543-51.
6. Sowenimo OA, Yood SM, Courtney J, et al. Natural history of morbid obesity without surgical intervention. Surg Obes Relat Dis 2007;3:73-7.
7. Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg 2004;240:416-23.
8. Sjostrom L, Narbro k, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish Obese Subjects. N Eng J Med 2007;357:741-52.
9. Adams T, Gress R, Smith S, et al. Long-term mortality after gastric bypass surgery. N Eng J Med 2007;357:753-61.
10. Peeters A, O’Brien P, Laurie C, et al. Substantial intentional weight loss and mortality in severely obese. Ann Surg 2007; 246:1028-33.
11. Busetto L, Mazza M, Miribelli D, et al. Comparative long-term after with laparoscopic adjustable gastric banding versus non-surgical controls. Surg Obes Relat Dis 2007;3:496-502.
12. Riess KP, Kothari SN, Baker MT, Lambert PJ, Mathiason MA. The effect of preoperative weight loss on laparoscopic gastric bypass outcomes. Surg Obes Relat Dis 2008;4:704-8
13. Still CD, Benotti P, Wood GC, et al. Outcomes of preoperative weight loss in high-risk patients undergoing gastric bypass surgery. Arch Surg 2007;142:994-8.
14. Alami RS, Morton JM, Schuster R et al. Is there a benefit to preoperative weight loss in gastric bypass patients? A prospective randomized trial. Surg Obes Relat Dis 2007;3:141-5.
15. Alger-Mayer S, Polimeni JM, Malone M. Preoperative weight loss as a predictor of long-term success following Roux-en-Y gastric bypass. Obes Surg 2008;18:772-5.
16. ASMBS Position Statement on Preoperative Supervised Weight Loss Requirements. Sur Obes Relat Dis 2011;7:257–260.

 

[Larra]

If this isn't already saved as a sticky, it should be.

 

[southernlady]

If this isn't already saved as a sticky, it should be.

It is now.

 

[Larra]

Thank you, @southernlady !

 

[DSRIGGS]

Bout damb time! Nice!

 

[DianaCox]

Doesn't mean the insurance companies will behave any differently.

 

[Larra]

True, the insurance companies aren't legally required to pay any attention to this or to make evidence decisions on coverage. Still, it will be useful for patients who run into this obstacle, esp if their case gets to the external appeal level.

 

[swimbikerun]

Diana Cox has it right. I had to wait a year and they could care less about the rest. Besides, a # of these bariatric surgeon practices are noted for lack of or incomplete/half baked followup, especially after 1 year.

 

[DSRIGGS]

I know Diana, but to me it is a huge step getting this group on record saying it is a bull shit ploy that can cost lives.. Fear can be a good thing...

 

[swimbikerun]

The problem is that they'd say go ahead and get the surgery without us. Its not a requirement to have elective surgery with our consent.

 

[Mermaid]

Anthem Blue Cross went the opposite direction from this ASMBS best practices statement, Anthem Added the following detailed requirement to their Bariatric policy as of 10/4/16. ARGH!!!!

Excerpt, Anthem Surg.00024:
The preoperative workup should include documentation by the treating physician of active participation in a formal weight reduction program for at least 6 months duration, in the 2 years prior to surgery, that includes serial documentation of all weights, as well as dietary and exercise regimens. Conservative weight loss efforts should be fully appraised by the physician requesting surgical authorization, so that preoperative assessment of the individual's capability for appropriate behavioral changes can be determined. A 6 month preoperative assessment of anticipated postoperative dietary compliance is a prudent indicator of anticipated postoperative successful weight loss which could be maintained over time. As further clarification of what constitutes reasonable documentation of active participation in a preoperative nonsurgical weight loss program, the following is suggested as relevant information to be documented in the medical record for a continuous sequential 6-month period in the 2 years prior to surgery:

• The documented appraisal should describe "what" the individual was actually doing in the program, that is were they following the diet and exercise recommendations as an active participant for six continuous months in the two years prior to surgery.
• The individual's weight should be documented at each preop visit including how much weight loss was achieved each month for the documented six month period.
• The documentation should include any specifics about "how" the surgeon and the nutrition team members guided and worked with the individual to encourage compliance and address any individual obstacles to enable positive behavioral changes prior to surgery.

 

[swimbikerun]

I had to wait a year.

The thing is, that also helps that people actually start making some changes before, that they need to stay the course. Otherwise, we end up with a lot of people who don't make the changes required to really make it more successful.

As DS'ers, do you really want people getting DS who aren't prepared, who aren't ready? Its a commitment.

 

[southernlady]

I had to wait a year.

The thing is, that also helps that people actually start making some changes before, that they need to stay the course. Otherwise, we end up with a lot of people who don't make the changes required to really make it more successful.

As DS'ers, do you really want people getting DS who aren't prepared, who aren't ready? Its a commitment.

I had no pre-op diet requirement although my surgeon typically does. But being so close to not qualifying at all, he didn't put me on one. And Medicare doesn't require them. Just attempts that have obviously failed.

I know I was eating pretty close to a DS way cause of my diabetes anyway. The DS just gave me the chance to actually lose weight.

 

[swimbikerun]

If you look on the FB groups, most of them aren't. There are more people who state they gain weight rather than stay the same weight when they see the surgeons. I don't know but it appears typical from what the FB people are saying in that they have surgeons who will allow them to lose weight or stay the same but they can't gain during the particular time frame, from seeing the surgeon to surgery.

You are discplined. There are loads of people who aren't. That's why the DS should be reserved for people like you.

I had no pre-op diet requirement although my surgeon typically does. But being so close to not qualifying at all, he didn't put me on one. And Medicare doesn't require them. Just attempts that have obviously failed.

I know I was eating pretty close to a DS way cause of my diabetes anyway. The DS just gave me the chance to actually lose weight.

 

[Larra]

@swimbikerun I respectfully disagree. For two reasons. First, there is no study that has ever shown that either mandatory months of pre-op doctor or dietician visits devoted to educating and/or developing new habits, or mandatory pre-op weight loss, predicts who will succeed or who will fail with bariatric surgery.
Second, people who are not well disciplined about what the eat can be very disciplined about eating plenty of protein, taking all their vitamins, regular lab work, etc. We have all encountered those people who have no idea what it's like to be MO, who believe that if we were just disciplined, had will power, ate like they eat (because they are better people than we are, I suppose) we would lose weight. We know now that weight loss is not about will power or discipline.
It's not about discipline. It's about treating a disease. The DS should be reserved only for people who meet the medical criteria for bariatric surgery and who are willing to make that commitment to a lifetime of protein, vitamins and labs.