Weight loss surgery, also known as bariatric or metabolic surgery, encompasses several procedures designed to help individuals with extreme obesity achieve significant and sustained weight loss. These surgeries modify the stomach and digestive system to limit food intake and alter nutrient absorption. However, accessing these potentially life-changing procedures through insurance like MassHealth requires meeting specific coverage criteria. This article aims to provide a comprehensive overview of MassHealth's requirements for weight loss surgery coverage, drawing upon expert guidelines, research findings, and considerations for patient safety and long-term success.
Understanding the Scope of Bariatric Surgery
Metabolic and bariatric surgery includes various surgical techniques that modify the stomach to reduce portion sizes and adjust how the body absorbs food, helping patients feel full faster and achieve a healthy weight. Many weight loss surgeries are now performed using minimally invasive techniques such as laparoscopic and robotic surgery.
These procedures can have a profound impact on an individual's health, addressing not only weight loss but also obesity-related conditions. Surgical outcomes focus on weight loss and the treatment of obesity-related diseases, like diabetes, sleep apnea, and others. Research shows accredited centers experience lower complications and better outcomes than that of non-accredited facilities.
MassHealth Coverage Policies: Key Considerations
MassHealth, like many insurance providers, has specific guidelines to determine medical necessity for procedures like excision of excessive skin and subcutaneous tissue. MassHealth requires prior authorization (PA) for excision of excessive skin and subcutaneous tissue. MassHealth reviews requests for PA on the basis of medical necessity. These guidelines are based on generally accepted standards of practice, review of the medical literature, and federal and state policies and laws applicable to Medicaid programs.
It's essential to recognize that "not all persons who are obese or who consider themselves overweight are candidates for bariatric surgery." The American College of Surgeons has stated these procedures are not for cosmesis but for prevention of the pathologic consequences of morbid obesity. The patient must be committed to the appropriate work-up for the procedure and for continuing long-term postoperative medical management, and understand and be adequately prepared for the potential complications of the procedure.
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Aetna's Approach to Obesity Surgery Coverage
It's worth noting that specific insurance plans, such as Aetna HMO and QPOS plans, often have their own stipulations. Most Aetna HMO and QPOS plans exclude coverage of surgical operations, procedures, or treatment of obesity unless approved by Aetna. Some Aetna plans entirely exclude coverage of surgical treatment of obesity.
Eligibility Requirements for Bariatric Surgery
To be considered a candidate for weight loss surgery, individuals generally need to meet specific criteria related to their Body Mass Index (BMI) and health status. To be a candidate for bariatric surgery, you also need to have: Body mass index (BMI) of 40 or more (about 100 pounds overweight) OR BMI between 30 and 39.9 AND a serious obesity-related health problem.
BMI Thresholds:
- A BMI of 40 or higher, which typically indicates being approximately 100 pounds overweight.
- A BMI between 30 and 39.9, accompanied by at least one serious obesity-related health problem.
Co-existing Health Conditions:
Weight loss surgery is often considered an effective treatment for many conditions, including: High cholesterol, Hypertension (high blood pressure), Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) - formerly called nonalcoholic fatty liver disease, Obesity, Obstructive sleep apnea, Type 2 diabetes.
The Importance of Behavioral Interventions
Recognizing the complexity of obesity and the need for a holistic approach, MassHealth and other healthcare organizations emphasize the importance of behavioral interventions as a prerequisite for surgery.
Intensive Multicomponent Behavioral Interventions
Member has participated in an intensive multicomponent behavioral intervention designed to help participants achieve or maintain weight loss through a combination of dietary changes and increased physical activity. Member's participation in an intensive multicomponent behavioral intervention must be documented in the medical record. Records must document compliance with the program. For members who participate in an intensive multicomponent behavioral intervention (e.g., Jenny Craig, MediFast, Minute Clinic/Health Hubs, OptiFast, Weight Watchers), program records documenting the member's participation and progress may substitute for medical records.
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The Preventive Services Task Force (USPSTF, 2019) recommends that clinicians offer or refer obese adults to intensive, multicomponent behavioral interventions (ie, behavior-based weight loss and weight loss maintenance interventions). The USPSTF found adequate evidence that behavior-based weight loss interventions in adults with obesity can lead to clinically significant improvements in weight status and reduced incidence of type 2 diabetes among adults with obesity and elevated plasma glucose levels.
Most of the intensive behavioral weight loss interventions considered by the USPSTF lasted for 1 to 2 years, and the majority had 12 or more sessions in the first year (USPSTF, 2019; LeBlanc, et al., 2018). Interventionists varied across the trials, and interventions included varied interactions with a primary care clinician (USPSTF, 2019; LeBlanc, et al., 2018). Primary care clinician involvement ranged from limited interactions with participants in interventions conducted by other practitioners or individuals (i.e., group-based interventions conducted by lifestyle coaches or registered dietitians) to reinforcing intervention messages through brief counseling sessions. Few interventions included a primary care clinician as the primary interventionist over 3 to 12 months of individual counseling.
Trials used various delivery methods (group, individual, mixed, and technology- or print-based). Group-based interventions ranged from 8 group sessions over 2.5 months to weekly group sessions over 1 year (median, 23 total sessions in the first year (USPSTF, 2019; LeBlanc, et al., 2018). These interventions consisted of classroom-style sessions lasting 1 to 2 hours. Most of the individual-based interventions provided individual counseling sessions, with or without ongoing telephone support. The remaining interventions were provided remotely through telephone counseling calls (average time, 15-30 minutes) and web-based self-monitoring and support. The median number of sessions in the first year for individual-based interventions was 12. Mixed interventions included comparatively equal numbers of group- and individual-based counseling sessions, with or without other forms of support (eg, telephone-, print-, or web-based). Among technology-based interventions, intervention components included computer- or web-based intervention modules, web-based self-monitoring, mobile phone-based text messages, smartphone applications, social networking platforms, or DVD learning (USPSTF, 2019; LeBlanc, et al., 2018).
The Role of Dietetic Counseling and Behavioral Modification
The American Dietetic Association (1997), in their position statement obesity surgery, recommends dietetic counseling and behavioral modification commencing prior to, not after, surgery: "Careful dietetics evaluation is needed to determine if the patient will be able to comply with the postoperative diet. Candidates for obesity surgery should begin a weight reduction diet prior to surgery. The purpose of a pre-operative nutrition program prior to obesity surgery are to test patient motivation, to reduce perioperative morbidity, to accustom patients to the restriction of food intake after surgery, and to increase total weight loss (van de Weijgert et al,1999; Jung and Cusciheri, 2000; Pekkarinen et al, 1997; Martin et al, 1995).
Pre-Operative Psychological Clearance
For members who have an active substance abuse disorder, or have a history of eating disorder (in addition to obesity) or severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist, pre-operative psychological clearance is necessary in order to exclude members who are unable to provide informed consent or who are unable to comply with the pre- and post-operative regimen.
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The Importance of Pre-Operative Weight Loss
A Multidisciplinary Care Task Group (Saltzman et al, 2005) conducted a systematic review of the literature and recommended an attempt at modest weight loss before obesity surgery, citing evidence that modest reductions in weight (5 to 10% of initial weight) reduce factors known to increase surgical risk (e.g., sleep disordered breathing, hypertension, hyperglycemia), and that with weight loss, obese patients had significantly shorter operating room times and length of stay.
Benefits of Pre-Operative Weight Reduction
Even super obese patients (BMI greater than 50) may benefit from initiating a nutrition and exercise program prior to surgery. Obesity itself increases the likelihood of pulmonary complications and wound infections (Choban et al, 1995; Abdel-Moneim, 1985; Holley et al, 1990; Myles et al, 2002; Nair et al, 2002; Bumgardner et al, 1995; Perez et al, 2001; Chang et al, 2000; Printken et al, 1975). The higher the patient's BMI, the higher the surgical risk, and the highest risks occur among patients with a BMI over 50 (Gonzalez et al, 2003; Oelschlager and Pellegrini, 2003). Even relatively modest weight loss prior to surgery can result in substantial improvements in pulmonary function, blood glucose control, blood pressure, and other physiological parameters (Anderson et al, 2000; Hakala et al, 1995; Kansanen et al, 1998; Pekkarinen et al, 1998). Factors such as blood glucose control, hypertension, etc., affect surgical risk.
Garza (2003) explained that the patient should lose weight prior to surgery to reduce surgical risks. "The overall health of patients should be optimized prior to surgery to reduce the potential for complications. Patients ought to be encouraged to lose as much weight as possible before surgery" (Garza, 2003).
Addressing Patient Compliance and Surgical Outcomes
Given the importance of patient compliance in diet and self-care in improving patient outcomes after surgery, the appropriateness of obesity surgery in noncompliant patients should be questioned. There is rarely a good reason why obese patients (even super obese patients) can not delay surgery in order to undergo behavioral modification to improve their dietary and exercise habits in order to reduce surgical risks and improve surgical outcomes.
Multidisciplinary Care and Support
The American College of Surgeons (ACS) has stated that the surgeon performing the bariatric surgery be committed to the multidisciplinary management of the patient, both before and after surgery. The ACS recommended: "They develop skills in patient education and selection and are committed to long-term patient management and follow-up. There is active collaboration with multiple patient care disciplines including nutrition, anesthesiology, cardiology, pulmonary medicine, orthopedic surgery, diabetology, psychiatry, and rehabilitation medicine.
The Bariatric Surgery Team
Ideally, the surgical center where surgery is to be performed should be accomplished in bariatric surgery with a demonstrated commitment to provide adequate facilities and equipment, as well as a properly trained and funded appropriate bariatric surgery support staff. This team should include experienced surgeons and physicians, skilled nurses, specialty-educated nutritionists, experienced anesthesiologists, and, as needed, cardiologists, pulmonologists, rehabilitation therapists, and psychiatric staff.
Types of Bariatric Procedures Covered
MassHealth coverage extends to various bariatric procedures, each with its own approach to achieving weight loss.
Common Bariatric Procedures
- Roux-en-Y Gastric Bypass (RYGB): In a RYGB procedure, your surgeon creates a “shortcut” from your stomach to your small intestine. RYGB promotes weight loss by changing how your stomach and small intestine process food. Creating a smaller stomach pouch-Your surgeon forms a small upper section (about the size of a golf ball) while leaving the lower portion of the stomach in place. Bypassing a part of the your small intestine-The surgeon connects a section of the small intestine to the new pouch, allowing food to bypass the upper part of the intestine.
- Sleeve Gastrectomy: Sleeve gastrectomy is a non-reversible, minimally invasive procedure using laparoscopic or robotic surgery. The surgeon removes a large portion of the stomach during this procedure. The remaining tube-shaped stomach holds less food and promotes early feelings of fullness.
- Laparoscopic/Robotic Duodenal Switch (DS) Surgery: In this procedure, surgeons perform a sleeve gastrectomy (remove the outer portion of the stomach) so that the new stomach looks like a narrow sleeve. The upper small intestine gets divided and the lower intestine is divided much further down than the Gastric Bypass, so it is the most malabsorptive procedure. This part gets connected to the stomach. The remaining intestine is connected back to itself to allow enzymes and bile to mix with food, to support digestion.
- Laparoscopic/Robotic Single Anastomosis Duodenoileostomy with Sleeve Gastrectomy (SADI-S): In this procedure, surgeons perform sleeve gastrectomy (remove the outer portion (also called crescent) of the stomach) so that the new stomach looks like a narrow sleeve.
- Conversion and Revisional Surgery: Patients who’ve had a previous weight loss surgery can receive adjustments to that surgery in the form of reversals, modifications or conversions from one type of surgery to another.
Post-Operative Care and Lifestyle Adjustments
Bariatric surgery is not a singular event but rather the start of a transformative journey. Post-operative care, lifestyle adjustments, and ongoing support are critical for long-term success.
Dietary Progression and Nutritional Guidance
Then, you'll follow a specific diet for a few weeks, starting with liquids only, then to very soft foods, and eventually, to regular foods. Following surgery, patients have to follow a careful diet of nutritious, high-fiber foods in order to avoid nutritional deficiencies, dumping syndrome, and other complications. The total weight loss from surgery can be enhanced if it is combined with a low-calorie diet.
Weight loss surgery patients need to learn important new skills, including self-monitoring and meal planning. Many forms of weight loss surgery require patients to take lifelong nutritional supplements and to have lifelong medical monitoring. Dedicated dietitians can help patients during their pre-operative education on new dietary requirements and stipulations and their post-surgical adjustment to those requirements.
Exercise and Physical Activity
You should avoid high-impact exercise and lifting anything heavier than 10 pounds for at least four weeks after surgery. In the first few weeks after surgery, you may be less energetic due to a lower-calorie intake (liquid diet).
Psychological Support
At the Mass General Weight Center, your care team develops an individualized plan to support you after weight loss surgery. Follow-up care includes regular visits with your surgical team, registered dietitian, and psychologist for the first 18 months.
Addressing Potential Complications
Conversion and revision surgeries have higher risks than the first weight loss surgery you received. This is because conversional and revisional bariatric surgeries try to correct an already-existing complication with another surgery. Your experienced Mass General surgeon will create a surgical plan that seeks to minimize your risk for complications.
Finding a Qualified Bariatric Surgery Center
Severely obese persons are at increased risk of surgical complications. Ideally, the surgical center where surgery is to be performed should be accomplished in bariatric surgery with a demonstrated commitment to provide adequate facilities and equipment, as well as a properly trained and funded appropriate bariatric surgery support staff.
Volume and Outcomes
A number of studies have demonstrated a relationship between surgical volumes and outcomes of obesity surgery. Most recently, an assessment by the Canadian Agency for Drugs and Technologies in Health (CADTH) (Klarenbach et al, 2010) stated that their volume-outcome review found that higher surgical volumes were associated with better clinical outcomes.
Accreditation and Recognition
Mass General is a designated Blue Distinction Center for Bariatric Surgery from Blue Cross Blue Shield of Massachusetts. Mass General Weight Center is a participating program in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and has earned the distinction of a MBSAQIP comprehensive center with adolescent qualifications. The Weight Center at UMass Memorial Medical Center in Worcester is an accredited Comprehensive Center for Weight Loss Surgery. We’ve maintained this accreditation from the American College of Surgeons Metabolic and Bariatric Accreditation and Quality Improvement Program since 2006. Our bariatric program is also a designated Blue Distinction Center+ by Blue Cross and Blue Shield companies. We are recognized for delivering high-quality, cost-efficient care and better overall patient outcomes.
Navigating the Insurance Process
Insurance coverage for weight loss surgery varies by plan and may have different eligibility requirements. If you’re interested in surgery, ask your primary care or referring provider to submit a referral to the Mass General Weight Center.
Understanding Costs and Coverage
For surgeries or procedures, it's hard to predict your costs in advance. This is because you won’t know what services you need until you meet with your provider. If you need weight loss surgery or a procedure, you may be able to estimate how much you'll have to pay. and a hospital outpatient department.Find out if you're an inpatient or outpatient because what you pay may be different.Check with any other insurance you may have to see what it will pay. , contact your plan for more information. if you expect to be admitted to the hospital.Check your Part B deductible for a doctor's visit and other outpatient care.You'll need to pay the deductible amounts before Medicare will start to pay.
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