Policy Change Means Greater Access to Bariatric Surgery

Published in February Issue             

TRICARE beneficiaries with severe obesity will now be covered for sleeve gastrectomy thanks to a policy change made in December 2015 by the health care program for members of the military and their families.

“Among the major insurers, TRICARE was essentially the last hold out on sleeve gastrectomy coverage,” said John M. Morton, MD, immediate past president, ASMBS. “The ASMBS and its partners had been meeting and providing data to TRICARE for about two-and-a-half years prior to this change. We are very pleased they have now joined nearly every other health plan in providing coverage for what has become the most common bariatric procedure in America.”

According to the ASMBS, about 193,000 people had bariatric surgery in 2014, and sleeve gastrectomy was found to be the most common procedure, accounting for 51.7 percent of weight-loss operations, followed by gastric bypass (26.8%), gastric band (9.5%), and biliopancreatic diversion with duodenal switch (0.4%).

In addition to covering sleeve gastrectomy, TRICARE also updated its policy to include coverage of biliopancreatic diversion and biliopancreatic diversion with duodenal switch for individuals with a BMI ≥50 kg/m2. Coverage of these procedures is retroactive as of September 1, 2014.

In May 2012, the ASMBS issued a position statement on sleeve gastrectomy concluding “substantial comparative and long-term data have now been published in peer-reviewed studies demonstrating durable weight loss, improved medical co-morbidities, long-term patient satisfaction, and improved quality of life after sleeve gastrectomy. The ASMBS therefore recognizes sleeve gastrectomy as an acceptable option as a primary bariatric procedure and as a first-stage procedure in high-risk patients as a part of a planned
staged approach.”

In 2013, the ASMBS, along with the American Association of Clinical Endocrinologists (AACE) and The Obesity Society (TOS), updated its clinical practice guidelines to include laparoscopic sleeve gastrectomy as a primary bariatric and metabolic procedure. That same year the Centers for Medicaid and Medicare Services (CMS) began routinely covering the procedure nationwide and insurers throughout the country soon followed suit.

Dr. Morton, Wayne English, MD, Chair and Co-Chairs John Scott, MD and Brandon Williams, MD of the Access to Care Committee led ASMBS efforts with TRICARE.

“Bariatric surgery remains the most effective method of weight loss and sleeve gastrectomy is an important option that should not be excluded because it’s among the newer procedures,” said Dr. English. “TRICARE did the right thing and we as a society and health professionals will continue to work very hard so that our patients have access to life changing, and in many cases, life-saving procedures. Insurers cannot afford to not cover bariatric surgery.”