Original Article

Obesity

PEDIATRIC OBESITY

Access to Care for Adolescents Seeking Weight Loss Surgery Thomas H. Inge1, Tawny W. Boyce1, Margaret Lee2, Linda Kollar1, Todd M. Jenkins1, Mary L. Brandt2, Michael Helmrath1, Stavra A. Xanthakos1, Meg H. Zeller1, Carroll M. Harmon3, Anita Courcoulas4, and Marc P. Michalsky5

Objective: Adolescents seeking weight loss surgery (WLS) frequently encounter obstacles obtaining treatment authorization from insurance carriers. This study identified factors influencing authorization for adolescents with clinical indications for WLS. Methods: A retrospective review was conducted for adolescents with clinical indications for WLS at five adolescent centers. This cohort represented a consecutive series of adolescents with insurance benefits for WLS for whom insurance authorization was sought between 2009 and 2011. Outcomes included number and timing of insurance authorizations for surgery, denials, and appeals. Results: Records from 57 adolescents (74% female; mean age 16 (range: 12-17) years; mean BMI 51.3 kg/m2) were reviewed. Of these, only 47% were approved with the original request. Eighty percent of those denied were approved on appeal, while 11% never obtained authorization for surgery. Age less than 18 years and proposed procedure were the most common reasons for denial. Conclusions: Less than half of adolescents with clinical indications for surgery received approval for the procedure on the first request. The appeal process typically resulted in overturning of denials, so that surgical care could be delivered. Obesity (2014) 22, 2593–2597. doi:10.1002/oby.20898

Introduction Severe obesity is a major problem affecting the health and psychosocial wellbeing of adolescents (1). Although behavioral and lifestyle interventions for severe obesity would be preferable to surgery, they are minimally effective in adolescents with severe obesity (1, 2). In contrast, tangible and long-term health and survival benefits of weight loss surgery (WLS) have been documented for severely obese adults (3-6), prompting the use of WLS to similarly obese adolescents, based on clear clinical practice guidelines (7-11). The frequency of adolescent bariatric procedures increased from the late 1990s to 2003. However, from 2003 to 2009, the rate plateaued at 2.3 per 100,000 adolescents, or 1,000 cases per year in the US (12). This trend may be related to patient factors, physician attitudes, and referral decisions (13, 14), or availability of insurance coverage (15). Obtaining access to bariatric surgical care for both adults and adolescents is dependent upon clinical factors (e.g., pres-

ence of indications for surgery, lack of contraindications), the existence of healthcare benefits for surgical treatment, and ultimately, authorization for use of such benefits by the healthcare insurance company. Insurance coverage for bariatric surgery in adults is largely predictable; if surgery is a covered benefit under the policy, and adults meet specified clinical criteria, 80–85% of initial requests for authorization are approved (16-18). However, for adolescents, the authorization process is complex and far less predictable. Insurers have discretion to approve or deny surgical benefits even for those who meet specified clinical criteria for WLS. Adding to the complexity are inconsistent responses even within the same company when authorization is requested. This is likely due to variation between insurance programs, products, and policies within the insurance company. As a result, there can be major time delays and cost effectiveness of providing care to insured patients is compromised by the significant amount of time required by providers, insurers, and families to navigate this complex system.

1

Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA. Correspondence: Thomas Inge ([email protected]) 2 Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA 3 Women & Children’s Hospital of Buffalo, Buffalo, New York, USA 4 University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA 5 Nationwide Children’s Hospital, Columbus, Ohio, USA.

Disclosure: Dr. Inge has received research grant funding from Ethicon Endosurgery, outside the submitted work. Dr. Michalsky has received research grant funding from Allergan Medical, outside the submitted work, and serves as a proctor and speaker for Covidien. Dr. Harmon has served on an Advisory Panel for Stryker Corporation. Dr. Courcoulas has received research grants from Allergan, Pfizer, Covidien, EndoGastric Solutions, and Nutrisystem, outside the submitted work, and is on the Scientific Advisory Board of Ethicon J & J Healthcare System. All other authors have nothing to disclose. Author contributions: Dr. Inge contributed to the design of the study and the analysis and interpretation of data. Ms. Kollar contributed to the design of the study, data collection, data management, and data interpretation. Dr. Jenkins and Ms. Boyce were responsible for data management, as well as analysis and interpretation. Drs. Brandt, Harmon, Courcoulas, and Michalsky acquired data and interpreted findings. Drs. Helmrath, Xanthakos, and Zeller interpreted findings. Ms. Lee carried out data collection. All authors were involved in the drafting and critical revisions of the manuscript and have approved the final submitted version. This work was previously presented as a poster at The Obesity Society (TOS) meeting in November 2013 at which time it was awarded for Excellence in Health Service Research by the Health Services Research Section of TOS. Received: 14 April 2014; Accepted: 19 August 2014; Published online 19 September 2014. doi:10.1002/oby.20898

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Obesity | VOLUME 22 | NUMBER 12 | DECEMBER 2014

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Obesity

Access to Care: Adolescents Seeking WLS Inge et al.

To date, there is no information available to help inform families and providers about what to expect when attempting to access insurance benefits for adolescent WLS. Further, data are not available pertaining to timing of the authorization, process, and factors associated with approval or denial, and reasons for denial of coverage. The aim of this study was to collect objective data to describe the process and outcomes for adolescents seeking authorization for a WLS procedure at centers with dedicated teams of adolescent WLS providers. We hypothesized that the majority of requests for insurance authorization for adolescents would be denied initially, that most denials would be based on age of the patient, and that most denial decisions would be overturned on appeal.

TABLE 1 Categorization of comorbidities as previously defined

(21) Major comorbidities 1. Type 2 diabetes mellitus 2. Obstructive sleep apnea syndrome 3. Pseudotumor cerebri

Methods This study was designed to retrospectively gather administrative and clinical data collected at each of five clinical centers who are actively engaged in adolescent bariatric treatment and clinical research (19, 20). Inclusion criteria for this study were confirmation of coverage for WLS by the patient’s insurance company, age  17 at time insurance authorization request was submitted, and a patient meeting current recommended clinical criteria for WLS as previously described (7). Indeed, Table 1 provides the clinical criteria which were used to categorize eligibility for surgery based on BMI, major, and minor comorbidities as previously described by Pratt et al. (7). Finally, to be included in this study, submission of a Letter of Medical Necessity (LOMN) to an insurance company between January 1, 2009 and January 1, 2011 was also required, to provide discrete inclusion boundaries to the study population. Records were reviewed by research coordinators and the following data were abstracted: age, BMI, gender, race, presence of major or minor co-morbidities (Table 1), type of insurance coverage, type of bariatric surgery sought (roux en Y gastric bypass [RYGB] or vertical sleeve gastrectomy [VSG]), LOMN submission date, date of approval, date(s) and reason(s) for denial of coverage, date(s) of appeals, and date of surgery. The following patients were excluded from analysis: patients  18 years of age at the time the LOMN was sent (n 5 13), patients seeking an adjustable gastric band (n 5 1) because it is not an approved procedure for patients under the age of 18, those for whom a determination was made by the program staff that insurance benefits for WLS did not exist at the time the LOMN was submitted (n 5 3), those for whom the patient or family withdrew from consideration of surgery after team evaluation or after letter requesting authorization had been submitted but before a decision was made by the payor, defined as the insurance source (n 5 3), or those with outstanding decisions by the payor at the time of the abstraction (n 5 1). All five of the clinical programs participating in this study routinely made an initial determination about whether a patient’s healthcare insurance policy indicated that WLS was an “exclusion” prior to requesting insurance authorization for WLS, and also verified all policy-stipulated clinical requirements when bariatric surgery was a covered benefit. However, no attempt was made to standardize the language or content of the LOMN documents among the programs. IRB approval was obtained to conduct this retrospective analysis with informed consent waived. Data were abstracted in a deidentified fashion with a unique identifier assigned to each case at each of the five adolescent bariatric centers. A Research Electronic

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Minor comorbidities 1. Hypertension; or 2. Dyslipidemias; or 3. Nonalcoholic steatohepatitis; or 4. Venous stasis disease; or 5. Significant impairment in activities of daily living; or 6. Intertriginous soft-tissue infections; or 7. Stress urinary incontinence; or 8. Gastroesophageal reflux disease; or 9. Weight-related arthropathies that impair physical activity; or 10. Obesity-related psychosocial distress

Data Capture (REDCap) database was used for online collection of required data elements. A data dictionary was also distributed to research coordinators at each clinical center. Descriptive statistics were calculated to characterize those individuals seeking payor approval for WLS. Frequencies and percentages were used to report categorical data, while means and standard deviations (SD) or medians and interquartile ranges (IQR) were used for continuous variables. Race was collapsed into two categories, white and non-white. Insurance categories were collapsed into Private, Public (Medicare and Medicaid), and Military. All patients with both major and minor comorbidities were categorized as major to prioritize severity. Number of days until initial decision was calculated as the number of days from LOMN submission to the initial determination of approval or denial; this number does not take into consideration time for appeals. Comparisons between those who were initially approved and those that were initially denied by their payor were evaluated using chi-square, Fisher’s Exact, Wilcoxon– Mann–Whitney, and t-tests. All reported P-values are two-sided and considered statistically significant at  0.05.

Results Fifty-seven patients meeting inclusion/exclusion criteria were identified. There were 42 girls and 15 boys, with average age of 16.0 years (range 12.3-17.9 years; Table 2). The patients resided in 10 states, with the following breakdown: AL, 5%; AZ, 2%; IN, 7%; KY, 14%; MD, 2%; MI, 2%; OH, 26%; PA, 14%; TX, 24%; WV, 4%. The racial composition of the cohort was 77% White, 15% Black, and 8% multirace; the mean BMI was 51.3 kg/m2 (range 38-77 kg/m2). Payors were primarily public or commercial insurance sources: Medicaid/Medicare, 42.1%; private insurance, 56.1%; military insurance 1.8%. The majority of participants (59.7%) had major comorbidities of obesity (as defined by Pratt et al. (7)). Of the 57 cases, only 27 (47.4%) were approved following the initial request (Table 2 and Figure 1). The median time from submission of the LOMN to an initial decision (approval or denial) by the payor was 23 days (range: 1-400, IQR: 17, 32), and this did not vary based on initial approval or initial

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Original Article

Obesity

PEDIATRIC OBESITY

TABLE 2 Demographic data of initial assessment approvals and denials

All subjects Female, n (%) Mean body mass index (SD) Mean age (SD) White, n (%) Comorbidities, n (%) Major Minor Planned procedure, n (%) Roux en Y gastric bypass Vertical sleeve gastrectomy Insurance, n (%) Public Private Tricare (military) Median days to initial decision (IQR) (n 5 55)

42 51.3 16.0 44

(74%) (8.89) (1.34) (77%)

Initial request approved, n 5 27 20 51.6 16.4 19

(74%) (8.11) (1.41) (70%)

Initial request denied, n 5 30 22 51.1 15.6 25

(73%) (9.68) (1.18) (83%)

34 (60%) 23 (40%)

20 (74%) 7 (26%)

14 (47%) 16 (53%)

38 (67%) 19 (33%)

22 (82%) 5 (19%)

16 (53%) 14 (47%)

P-value 0.95 0.84 0.03 0.24 0.03

0.02

0.89 24 (42%) 32 (56%) 1 (2%) 23.0 (17.0, 32.0)

denial of the request. However for the 24 individuals who were initially denied and then approved after 1-4 appeals, the median time from LOMN submission to ultimate approval was 93 days

11 (41%) 16 (59%) 0 (0%) 23.0 (17.0, 32.0)

13 (43%) 16 (53%) 1 (3%) 25.5 (16.5,35.0)

0.76

(IQR: 57, 217) compared to 23 days (IQR: 17, 32) for those approved initially. For one individual, 588 days elapsed prior to approval. Specific reasons for initial denial included: age

Access to care for adolescents seeking weight loss surgery.

Adolescents seeking weight loss surgery (WLS) frequently encounter obstacles obtaining treatment authorization from insurance carriers. This study ide...
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