Obesity is a growing concern in the United States, impacting a significant portion of the adult and youth populations. It's essential to understand the landscape of obesity treatment, particularly concerning metabolic and bariatric surgery (MBS) coverage under Medicaid. This article delves into the requirements and considerations surrounding Medicaid coverage for weight loss surgery, drawing upon available data and guidelines.
The Growing Obesity Epidemic and Its Consequences
Obesity rates in the United States are escalating, affecting approximately 30-36% of adults and 17% of young individuals. The prevalence of obesity tends to increase with age in both sexes. While racial and ethnic disparities are more pronounced in women, income and education levels also play a role. Higher-income non-Hispanic Black and Mexican-American men are more prone to obesity, while higher-income women are less likely to be obese. Similarly, women with college degrees are less likely to be obese compared to their less-educated counterparts. Alarmingly, obesity is on the rise across all income and education brackets.
The surge in obesity is closely linked to the increasing incidence of type 2 diabetes mellitus. A staggering 81% of new diabetes cases occur in obese individuals (BMI > 30), with 49% exhibiting class II or III obesity (BMI > 35). Obesity-related conditions, including stroke, heart disease, type 2 diabetes, and certain cancers (esophagus, breast -postmenopausal, endometrium, colon and rectum, kidney, pancreas, thyroid, and gallbladder), contribute significantly to the annual medical costs associated with obesity treatment, estimated at $147 billion in 2008.
Medicaid Coverage for Obesity Treatment: A Comprehensive Approach
Recognizing the multifaceted nature of obesity and its associated health risks, a comprehensive approach to treatment is crucial. The STOP Obesity Alliance, in collaboration with the Obesity Action Coalition, conducted an analysis of state Medicaid programs to assess their coverage of comprehensive obesity care elements, including:
- Nutrition Counseling (NC)
- Intensive Behavioral Therapy (IBT)
- Obesity Medications (OM)
- Metabolic and Bariatric Surgery (MBS)
This review involved examining the top Managed Care Organization (MCO) and Fee for Service (FFS) plans for each state's Medicaid program, with data extracted by LEVERAGE, a solutions and consulting firm, for the 2023 plan year.
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Unpacking the Medical Necessity Criteria
To determine coverage eligibility, states often employ medical necessity criteria, encompassing BMI levels, specified co-morbid conditions, and definitions of surgical complications. The extracted data was analyzed to gauge the level of coverage provided for each treatment category, categorized as:
- Covered
- Not Covered
- Covered with Limitations
- Covered with Restrictions
Limitations and restrictions are defined as barriers to accessing covered treatments. A limitation refers to a patient-level criterion, such as a clinical parameter or provider decision, that must be met to access treatment.
Dissecting the Components of Comprehensive Obesity Care Coverage
Nutrition Counseling (NC)
Few states explicitly address NC for obesity treatment, unless it is tied to MBS requirements. In cases where states are not explicit about this coverage, fee schedules are used to interpret coverage where necessary.
Intensive Behavioral Therapy (IBT)
Similar to NC, few states explicitly cover IBT.
Obesity Medications (OM)
The review of medications covered for obesity involves examining the state's Fee for Service and the top Managed Care Organization Prescription Drug List. The medications considered include both new generation medications (Saxenda and Wegovy) and older generation medications (Contrave, Qysmia, Phentermine, Benzphetamine, Diethylpropion, and Phendimetrazine). Xenical, Orlistat, and Alli are older generation medications that are now available over the counter.
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A "covered" designation indicates that the state will cover medication specifically for treating obesity (not for treating Type 2 diabetes with obesity as a secondary condition).
Metabolic and Bariatric Surgery (MBS)
A "covered" designation for MBS signifies that the state covers the procedure, and if a BMI value for coverage is available, it aligns with the American Society for Metabolic and Bariatric Surgery guidelines.
State-Specific Variations in Coverage
Each state receives a final value reflecting whether overall obesity treatment is covered, covered with limitations, covered with restrictions, or not covered. Certain states may impose restrictions on coverage based on age, such as covering only individuals aged 18-64 years or excluding those under 21 years or over 65 years.
Additional criteria that must be met for a repeat bariatric and metabolic surgery to be approved include a requirement that the patient (and/or provider) provide proof of compliance with all previously prescribed postoperative nutrition and exercise programs.
A patient could be excluded from coverage if there is a history of substance use disorder (SUD) now or in past; some states exclude patients with a SUD within a certain time.
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Specific Requirements for Bariatric Surgery Approval
To gain prior approval for bariatric surgery, patients typically need to fulfill specific requirements, demonstrating commitment and preparation for the procedure and its long-term implications. These requirements often include:
Participation in a Medically Supervised Weight Loss Program: Completion of six consecutive months of participation in a medically supervised weight loss program within the setting of a pre-surgical multidisciplinary evaluation is often required within one year before the prior approval request for the bariatric surgery.
Demonstration of Participant Responsibility: A key element is demonstrating the patient's commitment to the process.
Nutritional Assessment and Counseling: Regular nutritional assessment and counseling at each visit, including at least one visit with a registered dietitian or nutritionist. This includes dietary history, addressing any eating disorders, pre-surgical caloric reduction strategies, dietary behavior modification, and an understanding of the lifelong need for dietary changes.
Psychosocial-Behavioral Evaluation: A comprehensive psychosocial-behavioral evaluation conducted within 12 months of the prior approval request by a licensed psychologist, psychiatrist, clinical social worker, and/or advanced practice nurse in collaboration with a co-signing psychiatrist.
Education on Risks and Benefits: Thorough education regarding the risks and benefits of bariatric surgery, as well as available procedural options.
Language Interpretation: Ensuring effective communication by providing an interpreter when there is a clear communication barrier due to the patient's limited proficiency in English.
Optimization of Glycemic Control: Managing blood sugar levels to improve overall health.
Treatment of Dyslipidemia: Addressing abnormal lipid levels.
Discontinuation of Estrogen Therapy: If applicable, discontinuing estrogen therapy.
Cardiology Consultation and Beta-Adrenergic Blockade: Obtaining a cardiology consultation and initiating beta-adrenergic blockade, if indicated.
Preoperative Weight Loss: Considering preoperative weight loss to reduce liver volume and improve surgical outcomes.
Comprehensive Diagnostic Evaluation: Undergoing a thorough diagnostic evaluation, which may include:
- Chest radiograph (anterior posterior and lateral views)
- Pulmonary evaluation, including arterial blood gas measurement and polysomnography, if indicated
- Smoking cessation; addressing addiction to alcohol and drugs
- Diagnostic evaluation for deep venous thrombosis and vena cava filter, if indicated
- Abdominal ultrasonography and viral hepatitis screen
- Institution of CPAP or BiPAP as indicated for obstructive sleep apnea (OSA), obesity-hypoventilation syndrome (OHS), or Pickwickian syndrome.
Comorbidities That May Influence Coverage
The presence of certain comorbidities can significantly influence Medicaid coverage decisions for bariatric surgery. These may include:
Coronary artery disease documented by stress testing, previous need for angioplasty, or coronary bypass.
Peripheral arterial disease documented by arteriography or Doppler ultrasound of brachial and ankle pressures before and after exercise.
Cardiomyopathy documented by echocardiogram or MRI.
Pulmonary hypertension by echocardiogram.
Carotid artery disease documented by ultrasound with greater than 70% blockage at least unilaterally.
Aortic disease documented by CT or MRI.
Severe valvular disease documented by echocardiogram.
Medically refractory hypertension defined as a systolic pressure greater than or equal to 140 and/or a diastolic greater than or equal to 90 obtained by appropriately sized cuff despite treatment with at least 2 antihypertensive medications at maximum tolerable dosages.
Nonalcoholic fatty liver disease (NAFLD) / nonalcoholic steatohepatitis (NASH) with submission of liver function panel.
Dyslipidemia as defined by hypercholesterolemia greater than 240 mg/dl, hypertriglyceridemia greater than 400 mg/dl, low density lipoprotein greater than 160 mg/dl, or high density lipoprotein less than 40 mg/dl despite therapy with at least one lipid lowering agent at maximum dosage.
Pseudotumor cerebri.
Gastroesophageal reflux (GERD).
Asthma with severity at least of mild persistent.
Lower extremity venous/lymphatic obstructive stasis disease.
Severe urinary incontinence.
Degenerative osteoarthritis documented radiographically in any weight bearing joint or lumbosacral spine affecting performance of activities of daily living.
Uncontrolled type 2 diabetes mellitus.
Metabolic syndrome.
Considerations for Adolescent Patients
For adolescent patients seeking bariatric surgery, Medicaid coverage often requires the inclusion of a statement detailing at least one custodial parent or legal guardianâs commitment to support and facilitate the adolescent patientâs loss of weight, willingness to support, and facilitate permanent life style changes.
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