Aetna Inc., UnitedHealthcare to Cover Sleeve Gastrectomy—ASMBS Announces Support of Policy Changes

| May 19, 2010

GAINESVILLE, Florida—The American Society for Metabolic and Bariatric Surgery (ASMBS) announced its support of recent policy changes by Aetna Inc. and UnitedHealthcare. The national health insurance companies will now cover laparoscopic sleeve gastrectomy, a newer method of bariatric surgery that is becoming increasingly popular as a treatment for morbid obesity.

In sleeve gastrectomy, the stomach is surgically reduced to a thin, vertical sleeve that is about 15 percent of the original size of the stomach. Patients feel full faster and consume less, which results in significant weight loss and improved health.

Prior the policy change, Aetna and UnitedHealthcare classified sleeve gastrectomy as investigational and would not cover the procedure. Aetna began covering the procedure in April 2010 and United Healthcare began in October 2009. Other bariatric procedures covered by these and other insurers include Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and biliopancreatic diversion with duodenal switch.

Robin Blackstone, MD, FACS, Chairman of Access to Care Committee, ASMBS, said the ASMBS will continue working to improve access to care for bariatric and metabolic surgical procedures that eliminate, resolve, or improve obesity-related diseases like the remission of type 2 diabetes, hypertension, and sleep apnea.

Last year, the ASMBS joined with the Society for Alimentary Gastrointestinal and Endoscopic Surgery (SAGES) to request a procedure code from the American Medical Association (AMA). The requested was granted and a code (CPT 43775) was established for use on January 1, 2010. Procedure codes are used by insurers to identify surgical, medical, or diagnostic services, and to determine coverage and reimbursement.

Bariatric surgery is indicated for adults who have a body mass index (BMI) of 40 or higher or have a BMI of 35 accompanied by an obesity-related condition, such as type 2 diabetes or hypertension.
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Members of Bariatric Times Editorial Board react to the news

“We will continue to work with the medical community and coverage providers to improve access to bariatric and metabolic surgery so that we can more effectively meet the needs of patients. We hope other insurers will follow the lead of Aetna and United Healthcare and expand coverage to include sleeve gastrectomy as a medically necessary treatment option”

Robin Blackstone, MD, FACS
Chairman of Access to Care Committee, ASMBS; Associate Clinical Professor of Surgery, University of Arizona School of Medicine-Phoenix; Medical Director, Scottsdale Healthcare Bariatric Center, Scottsdale, Arizona

“Gastric bypass, laparoscopic band and gastric sleeve operations each pose different risks and benefits. Sometimes the sleeve is the safest operation. Other times the patient may not want the malabsorption problems from gastric bypass or a plastic foreign body from the band. Aetna and UnitedHealthcare are improving access to care for patients of size. Shame on all other insurance plans (including government insurance) who are restricting the surgeon’s options and patients say in healthcare decision-making.”

Daniel B. Jones, MD, MS, FACS
Chief, Section of Minimally Invasive Surgery, Beth Israel Deaconess Medical Center; Professor, Harvard Medical School, Boston, Massachusetts

“Its helpful to be able to offer more options to our patients, allowing us to better match the patient and the procedure. Specifically with the sleeve, it provides the metabolic benefits that a band does not offer, but presumably less interference with micronutrient absorption than the gastric bypass imparts.”

Liz Goldenberg, MPH, RD
Nutritionist, Weill Medical College of Cornell University; New York Presbyterian Hospital, New York, New York

“I am happy to see this change. So many patients will benefit from this less invasive procedure. The potential for lowering healthcare costs for all providers in the future and increase quality of living for the sleeve recipient is very high. This is a very welcome change indeed.”

Cynthia L. Alexander, PsyD
Psychologist, Program Coordinator, Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston; Examining Committee 17th Circuit Court of Florida, Fort Lauderdale, Florida

“There is no reason why other insurance companies should deny coverage for laparoscopic sleeve gastrectomy. As an originator of this laparoscopic procedure more than 10 years ago, I do not understand why it took so long, when one thinks that laparoscopic sleeve gastrectomy is, in fact, the first part of the duodenal switch, and many insurance companies cover duodenal switch. The FDA approved the LapBand as a device in June 2001, less than 10 years after it had started clinically in Belgium in 1992. The device had received its conditional approval after two FDA-monitored clinical trials (300 patients and 200 patients, with 3 years and 1 year follow up) with an overall 40-percent excess weight loss in American patients, and complication rates of 40 and 25 percent, respectively. Following this, insurance companies started to approve the procedure of laparoscopic gastric banding with these results (not with their own trials or mega study). We certainly have more than this in the literature for laparoscopic sleeve gastrectomy—excess weight loss greater than 60 percent with data from 3 to 5 years. In several countries where a national health system exists, sleeve gastrectomy is already an approved procedure, and in some, it is already performed more frequently than banding or bypass. We need a better process for surgical procedures approval. It should not be the FDA, and it should not be medical insurance companies.”

Michel Gagner, MD
Clinical Professor of Surgery, Herbert Wertheim College of Medicine, Florida International University, Miami Beach, Florida

“I have always been in favor of insurance coverage for bariatric surgery. It remains my opinion that the decision to perform a specific surgery is a private decision among the surgical interdisciplinary team and the patient. I hope as more sleeves are performed, the surgical program, under the direction of the bariatric surgeon, will provide outcome data across three fields of observation: 1) excess weight loss, 2) improvement in medical conditions or aggravation of such, and 3) patient perceived quality of life. After reviewing the literature, I have some concerns regarding my patients potential for increased reflux following the sleeve and how this might impact quality of life over time. It will be important to build upon evidenced-based research to best guide solid decision making while producing good-to-excellent long-term results. Such research can protect life and ensure continued insurance coverage for bariatric surgery.”

Melodie K. Moorehead, PhD, ABPP
Board Certified in Clinical Health Psychology, JFK Medical Center, Bariatric Wellness and Surgical Institute. A Center of Excellence, Atlantis Florida

“I applaud the decisions of Aetna, United Healthcare (and most recently Cigna) to cover the sleeve gastrectomy.  The published data certainly supports its inclusion as an option for patients seeking bariatric surgery in addition the band, the switch, and the bypass.  I hope that more health insurance companies follow suit because in regions such as the one I work in (New England) very few of my patients have Aetna, UnitedHealthcare, and Cigna and therefore only a very small percentage can chose the sleeve.”

Scott A. Shikora, MD, FACS

Professor of Surgery, Tufts University School of Medicine, Chief, Division of General Surgery, Chief, Bariatric and Minimally Invasive Surgery, Tufts Medical Center, Boston, Massachusetts


Category: News and Trends, Past Articles

Comments (2)

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  1. Barbara says:

    I have UHC insurance at my place of employment, but the gastric sleeve is excluded by my company. Is there anyway I can take out my own policy that will cover this surgery. I have already met with a physician who would preform the surgery and am ready to go. Can you help me?

    Thank you,