Portland, OR (PRWEB) June 06, 2013
More than one third of adults in the United States are obese, which places individuals at higher risk of morbidity from conditions and diseases such as hypertension, dyslipidemia, type 2 diabetes, and sleep apnea. Studies have shown that obesity-related diseases dramatically resolve or improve after bariatric surgery. As such, the number of weight-loss surgeries performed in recent years has increased. During a recent AllMed webinar, utilization review and case management professionals from payer organizations gained an understanding of the criteria many health plans use to determine medical necessity for bariatric surgery.
Dr. Julie J. Kim, a board-certified general surgeon, discussed issues related to determining medical necessity for bariatric surgery. Dr. Kim reviewed types of approaches to bariatric surgery. Restrictive procedures limit the amount of food intake by reducing the size of the stomach such as laparoscopic adjustable banding (LAGB), vertical sleeve gastrectomy and vertical banded gastroplasty (VBG). Malabsorptive procedures limit the absorption of foods in the intestinal tract by bypassing a portion of the small intestine. Purely malabsorptive procedures are rare and account for less than 5% of operations performed. Dr. Kim then discussed procedures that combine both restrictive and malabsorptive techniques such as gastric bypass with Roux-en-Y anastomosis (RYGB), the current gold standard for bariatric surgery and the most commonly performed procedure.
Longstanding treatment guidelines and practice parameters for bariatric surgery developed by the National Institutes of Health (NIH) require individuals to meet specific criteria in order to be considered candidates for surgery. According to Dr. Kim, weight loss surgery should be considered as a treatment of last resort, after first-line treatment involving diet, exercise, psychotherapy, and medications has failed. Criteria for patient selection for bariatric surgery are relatively uniform among various authors and correspond to criteria recommended by the American Society of Bariatric Surgery (ASBS) and the National Heart, Lung and Blood Institute (NHLBI). Indications include patient BMI of 40 kg/m2, or 35 kg/m2 with significant high-risk co-morbid disease (e.g., sleep apnea, type 2 diabetes) and documented failure of nonsurgical weight loss programs.
Additional ASBS and NHLBI criteria include:
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