AllMed Helps UR & Case Managers Learn About Medical Necessity Criteria for Bariatric Surgery

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Over one third of adults in the U.S. are obese and the number of weight-loss surgeries are increasing. In a recent webinar from AllMed, utilization review and case managers learned about the criteria for determining medical necessity for these procedures.

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"Weight loss surgery should be considered as a treatment of last resort, after first-line treatment involving diet, exercise, psychotherapy, and medications has failed." - Dr. Julie Kim

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:

  •     Acceptable operative risk
  •     Psychologically stable with realistic expectations
  •     Well-informed and motivated patient
  •     Supportive family/social environment
  •     Absence of uncontrolled psychotic or depressive disorder
  •     No active alcohol or substance abuse

“Although many health plans cover bariatric surgery for carefully selected patients who meet very specific criteria and have failed nonsurgical therapies,” said Dr. Kim, “patients need to have realistic expectations for these procedures, which are not cosmetic.” She also stressed that patients must have adequate support systems in place in order to facilitate compliance with postoperative follow-up care and dietary guidelines. Independent medical review not only helps to ensure that these criteria are met when determining medical necessity, but it also avoids conflicts of interest, which can relate to economics, lack of specialists to review cases, or having the same doctor who denied a case review an appeal.

About AllMed
AllMed Healthcare Management provides physician review outsourcing solutions to leading health plans, medical management organizations, TPAs and integrated health systems, nationwide. AllMed offers MedReview(sm), MedCert(sm), and MedDirector(sm) staffing services that cover initial pre-authorizations and both internal and external appeals, drawing on a panel of over 400 board-certified specialists in all areas of medicine. Services are deployed through PeerPoint(R), AllMed's state-of-the-art medical review portal. For more information on how AllMed can help your organization improve the quality and integrity of healthcare, contact us today at info(at)allmedmd(dot)com, or visit us at http://www.allmedmd.com.

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Kiki Grant
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