Real-World Experience With Insurance Coverage for Endoscopic Bariatric Therapies: A Cross-Sectional Analysis From a Large Academic Medical Center

Introduction: Despite substantial evidence for the safety and efficacy of endoscopic bariatric therapy (EBT) for weight loss, insurance coverage remains remarkably limited in the United States. Insurance reimbursement is an important determinant of patients’ access to care, as well as physicians’ compensation. We aimed to identify demographic, clinical, and procedural factors associated with insurance coverage for patients undergoing EBT. Methods: We performed a retrospective review of patients who underwent EBT for the treatment of obesity at a tertiary-care referral center between Jan 2020 and May 2023. All patients who received insurance coverage were included. Cash-pay patients were excluded. A control cohort of eligible patients denied by insurance was studied. The primary objective was to identify predictors for successful prior authorization and coverage. Secondary outcomes included the proportion of procedural costs covered by insurance. Results: A total of 158 patients were included (124 successfully received insurance coverage for EBT, and 34 controls with denied prior authorization) (Table 1). Among commercially available insurers, percentage of patients insured with Blue Shield (P< 0.0001) and Cigna Healthcare (P= 0.03) were significantly lower in the covered group compared to the denied authorization group {7% vs 38.2%, 1.6% vs 8.8%; respectively). No difference was found in the insurance coverage rate based on BMI > 30 kg/m2 alone, BMI >30 kg/m2 + 1 comorbidity, BMI 30 kg/m2 + 2 comorbidities, presence of diabetes, age, or gender. Significantly greater coverage was seen for patients undergoing revisional procedures compared to primary EBT (87.1% vs. 18.5%, respectively; P< 0.001). In a subgroup analysis performed for 57 ESG patients (Table 1), Cigna Healthcare had the lowest approval rate; however, no predictive clinical or demographic factors were found to predict better insurance approval for ESG. Conclusion: Revisional endoscopic procedures received better insurance coverage than primary endoscopic therapy. Although we identified two commercial insurers more frequently denied coverage in our cohort, no other predictive factors could be determined. These results indicate a lack of standardization and the state of outdated insurance policies that do not reflect the current efficacy data for ESG. As the need for less-invasive treatments for obesity grows larger, so does the critical appeal for expanded, transparent coverage of these treatments. Table 1. - Descriptive statistics for full cohort of patients either receiving insurance authorization for endobariatric therapy or denial (top), as well as subset of patients receiving authorization specifically for primary endoscopic sleeve gastroplasty or denial (bottom) Demographics Authorized (N=124) Denied (N=34) P-value Female, n (%) 99 (79.8) 27 (79.4) 0.96 Age, mean years (SD) 49.5 (10.9) 50.2 (12.0) 0.75 White, n (%) 69 (55.6) 9 (26.5) < .01 Black, n (%) 25 (20.2) 1 (2.9) 0.02 Hispanic, n (%) 18 (15.8) 5 (14.7) 0.98 Asian/Pacific Islander, n (%) 3 (2.4) 2 (5.8) .31 Other/Unknown, n (%) 10 (8.1) 17 (50.0) <.001 Clinical Characteristics BMI, mean (SD) 39.3 kg/m2 (6.8) 38.7 kg/m2 (10.0) 0.72 BMI > 35 kg/m2, n (%) 90 (72.6) 21 (61.8) 0.22 BMI > 30 + 1 comorbidity 116 (93.5) 31 (91.1) 0.63 BMI > 30 + 2 comorbidities 108 (87.1) 29 (85.3) 0.79 T2DM, n (%) 36 (29.0) 11 (32.4) 0.70 Procedural Characteristics Procedure performed ESG, n (%) 23 (18.5) - - Re-sleeve 21 (16.9) - - TORe, n (%) 43 (34.7) - - TORe-G, n (%) 34 (27.4) - - APC-TORe, n (%) 3 (24.2) - - Previous Surgery Any, n (%) 108 (87.1) 7 (20.6) < .001 RYGB 81 (65.3) 3 (0.9) < .001 Sleeve gastrectomy 21 (16.9) 0 0.01 Gastric Band 5 (4.0) 1 (2.9) 0.77 IGB 0 2 (5.8) 0.01 Coverage Details Procedure cost 100% covered, n (%) 32 (25.8) - - Mean copay by patient, $ (SD) 632.28 (1,017.0) - Insurance Characteristics Payor Anthem Blue Cross, n (%) 47 (40.9) 13 (38.2) 0.97 Blue Shield of California, n (%) 8 (7.0) 13 (38.2) < 0.0001 Medicare, n (%) 13 (11.3) 1 (2.9) 0.17 United Healthcare, n (%) 15 (13.0) 2 (5.9) 0.30 Cigna Healthcare, n (%) 2 (1.6) 3 (8.8) 0.03 Endoscopic Sleeve Gastroplasty Cohort Demographics Authorized for ESG (N=23) Denied (N=34) P-value Female, n (%) 16 (79.8) 27 (79.4) 0.14 Age, mean years (SD) 43.8 (10.9) 50.2 (12.0) 0.06 White, n (%) 11 (55.6) 9 (26.5) 0.10 Black, n (%) 2 (20.2) 1 (2.9) 0.95 Hispanic, n (%) 3 (15.8) 5 (14.7) 0.86 Asian/Pacific Islander, n (%) 0 (2.4) 2 (5.8) 0.24 Other/Unknown, n (%) 7 (8.1) 17 (50.0) 0.14 Clinical Characteristics BMI, mean (SD) 40.8 kg/m2 (8.2) 38.7 kg/m2 (10.0) 0.40 BMI > 35 kg/m2, n (%) 14 (60.9) 21 (61.8) 0.94 BMI > 30 + 1 comorbidity 19 (82.6) 31 (91.1) 0.33 BMI > 30 + 2 comorbidity 15 (65.2) 29 (85.3) 0.08 T2DM, n (%) 9 (39.1) 11 (32.4) 0.60 Insurance Characteristics Payor, n (%) Anthem Blue Cross 4 (17.4) 13 (38.2) 0.09 Medicare 2 (8.7) 1 (2.9) 0.34 United Healthcare 4 (17.4) 2 (5.9) 0.16 Blue Shield of California, 1 (4.3) 3 (8.8) 0.52 Cigna Healthcare 0 3 (8.8) 0.14 Others 4 (17.4) 0 0.01 P-values represents results from z-test for proportions or t-test. ESG; endoscopic sleeve gastroplasty, BMI; body mass index, T2DM; type 2 diabetes mellitus, TORe; transoral outlet reduction. TORe-G; transoral outlet reduction with gastroplasty, APC; argon plasma coagulation, RYGB; Roux-en-Y gastric bypass, IGB; intragastric balloon.