8 November, 2023

Does Insurance Cover Endoscopic Sleeve Gastroplasty?

The United States as a nation is unhealthy, ranking twelfth out of 125 for the highest percentage of obesity. Currently, just under three-quarters of the adult population in the United States is classified as overweight or obese, and almost half of them fall into the obese category. These statistics are triple what they were in the early 1960s, and they continue to get worse.

In the late 1960s, bariatric surgery came on the scene but was not utilized significantly until the mid- to late-1990s, when some popular celebrities had procedures and then shared their stories. Since then, great advancements have been made in the field of bariatrics, giving obese patients non-surgical alternatives for weight loss such as gastric balloons and endoscopic sleeve gastroplasty (ESG).

There are a few factors that have historically held patients back from getting the help they need to combat obesity. Today, we are going to talk about one of these factors: the cost of surgery and the use of health insurance coverage. We are going to outline what it takes to qualify before medical insurance will cover bariatric surgery and what insurance will pay for endoscopic sleeve gastroplasty.

Why Haven’t More Obese People Sought Help Through Bariatric Surgery?

Statistics show that only about 1% of the people who meet the basic qualifications for bariatric surgery actually move forward with it. There may be many factors that play into their decision not to move forward with surgery, including

No Health Insurance Coverage

Often, people who are unhealthy do not get the medical care they need because they cannot financially afford it. In 2021, statistics show that around 30 million Americans between the ages of 18 and 64 did not have health insurance.

They Do Not Meet The Qualifications For Bariatric Surgery

Some health insurance companies have provisions in their policies that cover at least one type of bariatric surgery for qualifying patients; however, the process to determine eligibility is lengthy and complicated.

Some patients are denied for legitimate reasons such as poor health or because their BMI is not within range, and others must jump through a series of hoops before they are approved, and they give up before they complete the process.

Insurance policies can have different criteria, limitations, and requirements before they will cover bariatric surgery, regardless of the patient’s high BMI. The Mayo Clinic outlines the qualifications that are most often used to determine eligible candidates:

  • Individuals who have unsuccessfully attempted to reduce their weight through traditional diet and exercise;
  • Individuals whose BMI is at least 40;
  • Individuals whose BMI is at least 35 and who also have a weight-related condition like hypertension or diabetes type II.

Many insurance companies also require patients to show proof of their weight loss efforts that span at least six months. Each surgeon may also have their qualifications before agreeing to perform the surgery.

The Individual Does Not Want To Have Surgery

Bariatric surgery has been shown to be an effective means for patients to lose weight, but many individuals are afraid to undergo surgery. They do not want to take the risk that they will experience complications or side effects from the surgery.

Financial Reasons

One of the drawbacks of bariatric surgery is the extended recovery time, and most people cannot afford to take the time off of work needed to recover. Statistics show that 60% of the labor force in the United States is paid hourly, which most often means if they do not work, they do not get paid.

Statistics also show that the highest rates of obesity tend to be in lower-income areas. Lack of income and the absence of insurance coverage often inhibit many patients from considering bariatric surgery.

There Is Hope On The Horizon For Obesity Statistics

There have been many advancements in the field of bariatrics, and today there are endoscopic procedures available that promote weight loss without surgery. This is great news and a viable alternative for the 99% of individuals who choose not to undergo surgery for one reason or another.

Endoscopic sleeve gastroplasty (ESG) is performed without incisions and as an outpatient procedure. It helps promote weight loss by reducing the capacity of the patient’s stomach so they eat less and stay full longer. The ESG procedure offers short recovery times (from 3 to 10 days) and has a very low-risk profile.

More Patients Will Qualify For These Endoscopic Weight Loss Options

These non-surgical procedures may have the potential to attract more obese patients to seek help and become healthier.

Qualifying For ESG Is Easier Than For Bariatric Surgery

Endoscopic weight loss procedures do not have the same qualifications as bariatric surgery, so more individuals would be considered candidates.

Patients who desire to use the Orbera balloon or ESG should have a BMI of around 27 or higher to be eligible. Patients can meet with a weight loss expert such as Dr. Okeefe Simmons of Simmons MD Advanced Weight Loss Solutions in Miami, FL, for an initial consultation and potentially undergo their non-surgical weight loss procedure fairly quickly.

Patients Can Get Help Faster

One of the most blatant disservices that obese patients have been presented with is the BMI qualification for eligibility to have bariatric surgery. The standard BMI scale lists any body mass index (BMI) above 29.9 as obese, and then there are classes of obesity based on how high the number is.

As we stated earlier, an individual must have a BMI of at least 35 before they qualify for surgery, and their BMI can only be under 40 if they have another condition that is obesity-driven. If they do not have an accompanying health condition, they have to have a BMI of at least 40.

According to these parameters, obese patient does not have the opportunity to get the help they need to get their weight under control until they become significantly more unhealthy. The patient must develop a weight-related disease or gain enough weight so their BMI reaches the qualification level.

For example, according to the standard BMI scale, an individual who is 5’ 7″ and weighs 191 pounds has a BMI of 30. For them to qualify for bariatric surgery with a BMI of 35, they would have to weigh 223 pounds, and if they didn’t have a health condition, they would have to wait until their BMI reached 40, which would put them weighing in at 255. So potentially, they would have to gain 64 pounds before they could get help! How does that even make sense?

Endoscopic weight loss options create the opportunity for patients to get help before their health gets significantly worse.

Insurance Coverage For Non-surgical Weight Loss Options

Lower BMI qualifications and effective, safe procedures that do not require surgery can alleviate a few of the factors that have kept many individuals living with untreated obesity.

However, there is still one factor that stands in the way of many receiving the help they need. It is the unfortunate answer to the question: Is endoscopic sleeve gastroplasty covered by insurance?

Currently, medical insurance companies do not offer coverage for ESG or endoscopic balloons. These procedures have not yet been considered methods used to improve a patient’s health; they are considered cosmetic weight loss procedures. Ongoing research continues to refute this belief, as these methods have been proven successful in significant numbers of patients who experienced a reduction or total remission of obesity-related illnesses after having an ESG or using the Orbera balloon.

Predicting The Future Of Insurance Coverage For Endoscopic Sleeve Gastroplasty

Currently, new procedures for weight loss like ESG are not yet recognized or approved by health insurance companies, so patients who want to have them must pay out of pocket. This is bad news because it leaves a good majority of obese patients stuck between a rock and a hard place. They need and want to lose weight; they do not wish to have surgery or are not candidates for surgery for health reasons and they cannot financially afford to self-pay.

There is hopeful news, however, as most experts agree that ESG will eventually be considered a covered procedure, and here’s why:

Losing Weight Reduces Health Risks

Losing weight has proven to improve an individual’s overall health and reduce their risk of:

  • Coronary disease and stroke;
  • Hypertension;
  • Severe sleep apnea;
  • Unhealthy cholesterol levels;
  • Asthma and other respiratory system problems;
  • Joint breakdown or Arthritis ;
  • Chronic gastroesophageal reflux disease;
  • Serious liver conditions;
  • Some cancers;
  • Urinary incontinence/bladder issues.

Obesity Costs Healthcare Providers A Lot Of Money

About $180 billion is spent annually in the U.S. on treating obesity-related conditions that affect American adults. Another almost $15 billion in costs can be attributed to treating illnesses in obese American children.

Obesity Costs Employers Time And Money

A study conducted by the Milken Institute using 2018 data determined that obesity was the biggest contributor, at almost 48 percent, when compared to all the other healthcare costs generated by chronic illnesses.

American employers are also affected by lost employee productivity, estimated at about $1.24 trillion.

ESG Has Recently Been Approved By The FDA

Non-surgical ESG has gained popularity significantly since the clinical trials reported that its weight loss potential rivals that of vertical sleeve gastrectomy. The data from these clinical trials was so significant that it convinced the FDA to grant its approval in June 2022.

ESG Has Fewer Associated Risks & Complications

An unfortunate but true fact is that medical insurance companies are not non-profit organizations; their objective is to make money. Surgical complications cost insurance companies money, and they want to mitigate their risk for any financial obligations.

ESG has shown to have a 2% complication rate compared to the 13% associated with gastric sleeve surgery (which is currently covered by most medical insurance plans and is also the most performed weight loss procedure).

ESG Is Less Expensive To Perform

Endoscopic sleeve gastroplasty is done as an outpatient procedure, so the patient does not need to spend any time in the hospital. The typical hospital stay costs almost $3,000 a day, which can increase the insurance company’s costs by $10,000 for just a simple gastric sleeve surgery.

Bariatric surgery is also more expensive to perform than the outpatient endoscopic weight-loss procedure. Check out this cost comparison of bariatric surgery vs. ESG.

Bariatric Surgery Costs vs. ESG Chart

Hospital Stay (Average) Cost For Procedure (National Average) Percentage of Complications (Average)
Endoscopic Sleeve Gastroplasty 0-1 days $10,000 2.1%
Vertical Sleeve Gastrectomy (Gastric Sleeve) 2-3 days $14,950 13.2%
Roux-en-Y (Gastric Bypass) 2-5 days $23,200 21%
Surgical Bariatric Lap Band 1-2 days $14,700 34%

Companies that provide medical insurance have an unmistakable opportunity to benefit from the cost savings associated with providing coverage for endoscopic sleeve gastroplasty. Not only the reduced costs of the procedure itself or the avoided costs of associated complications but also the huge chunk of change they are currently spending on prescription drugs and treatments to treat obesity-related illnesses.

If more patients had access to a non-surgical solution for their obesity, experts agree they would choose to take it. As patients become healthier, the fewer expensive healthcare treatments or medicines they require. It is a win-win for the patient and the insurance carrier.

How To Get Endoscopic Sleeve Gastroplasty Now

If you desire to have ESG now to help you lose weight and become healthier, you do not have to wait until the procedure is approved by your medical insurance provider. You have options!

  • Most weight loss doctors partner with companies that offer patient financing for procedures that are not currently covered under medical insurance plans;
  • You may also be able to take advantage of a flexible spending account that is specifically for health-related costs. This subtracts this amount of money from your taxable income;
  • Make an appointment with Simmons MD Advanced Weight Loss Solutions to find out if you are a good candidate for ESG and start your weight loss journey today.

Our caring experts are here to help you every step of the way on your journey to health. Come visit us today and let us share our knowledge and expertise with you and create a customized plan to help you meet your weight loss goals.

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