Preexisting GERD as a comorbidity?

[Res Ipsa]

Someone I know approached me on whether GERD is a comorbidity for insurance purposes. This person has a BMI of a bit over 35 and their primary medical health problem is a long-standing case of GERD (gastroesophageal reflux disease). Has anyone seen GERD accepted by a health insurer as a comorbidity to approve gastric bypass surgery?

[cinwa]

From what I've read, GERD is occasionally listed as a comorbidity but they seem few and far between:  https://www.obesitycoverage.com/insurance-and-costs/pre-approval-process/comorbidities

Less frequent comorbidities that are occasionally accepted by insurance include:

• Congestive Heart Failure
• Fatty Liver Syndrome
• Gall Bladder Disease
• Depression
• Stroke or Stroke Risk
• Inability to Carry Out Daily Activities
• Psychosocial Stress Resulting From Obesity
• GERD (Acid Reflux Disease)

[Aussie Bear]

Of course our insurance systems are different, but I've only ever seen GERD accepted as a reason for revisional surgery to be approved. There are other less invasive surgeries that can be performed to resolve GERD. Let's be realistic, insurers are going to go with the least expensive solution to an issue.

Edited February 11, 2019 by Aussie Bear

[Walter Lindstrom]

Hi folks,

A member asked me to comment on this even though it's an older thread so I'm happy to try helping out.

The RNY gastric bypass is considered the anti-reflux surgery of choice by surgeons in the field and I'm attaching a PDF with more information that might help.  The Recommendation is on page 8:  "Due to concerns for higher failure rates after fundoplication in the morbidly obese patient (BMI >35 kg/m2) and the inability of fundoplication to address the underlying problem (obesity) and its associated comorbidities, gastric bypass should be the procedure of choice when treating GERD in this patient group..."

GERD certainly is a central issue for band removal / conversion cases but also for sleeves which need revising due to new-onset GERD, which can be quite severe. Documenting the severity of the GERD will matter a great deal and it will be important to have a full reflux work-up establishing a failure of lifestyle modifications (e.g., eliminating acid reflux inducing foods like coffee, chocolate, red sauces, etc.), elevating head of bed, not eating after certain hours etc. with regard to reflux being improved. After lifestyle management "fails" it is important to demonstrate a failure of medical management with anti-reflux medicines will help establish medical necessity. It is really quite a misunderstood and under-appreciated comorbidity!  guidelines-for-surgical-treatment-of-gastroesophageal-reflux-disease-gerd.pdf

Hope this helps. Email or call us if there are questions or concerns I can help with.  The link is in my signature.

 

[Bezy]

On 5/24/2019 at 5:05 PM, Walter Lindstrom said:

Hi folks,

A member asked me to comment on this even though it's an older thread so I'm happy to try helping out.

The RNY gastric bypass is considered the anti-reflux surgery of choice by surgeons in the field and I'm attaching a PDF with more information that might help.  The Recommendation is on page 8:  "Due to concerns for higher failure rates after fundoplication in the morbidly obese patient (BMI >35 kg/m2) and the inability of fundoplication to address the underlying problem (obesity) and its associated comorbidities, gastric bypass should be the procedure of choice when treating GERD in this patient group..."

GERD certainly is a central issue for band removal / conversion cases but also for sleeves which need revising due to new-onset GERD, which can be quite severe. Documenting the severity of the GERD will matter a great deal and it will be important to have a full reflux work-up establishing a failure of lifestyle modifications (e.g., eliminating acid reflux inducing foods like coffee, chocolate, red sauces, etc.), elevating head of bed, not eating after certain hours etc. with regard to reflux being improved. After lifestyle management "fails" it is important to demonstrate a failure of medical management with anti-reflux medicines will help establish medical necessity. It is really quite a misunderstood and under-appreciated comorbidity!  guidelines-for-surgical-treatment-of-gastroesophageal-reflux-disease-gerd.pdf

Hope this helps. Email or call us if there are questions or concerns I can help with.  The link is in my signature.

 

I know you posted this about 9 months ago, but I found it very helpful. I am just now trying to pull together info to see if this surgery is a good choice for me.  But I feel as if I am always in the small percentage group on everything (I had a 100 lb loss that took 3 years and at just over 5 years after I’m headed back to the start after such a struggle not to do so). I have Blue Cross Blue Shield of Illinois and also TRICARE (select/retiree/East) - from what I can see (and after talking to a rep from BCBSIL) their list of co-morbidities is short and only the few major ones. Although she encouraged me to have my endocrinologist send in some paperwork asking for an authorization, and suggested that Blue Cross Blue Shield would almost have to be in a little on Matt, it does have me concerned.
 

I thought perhaps I might need to use both plans to cover the testing, etc. up until just before the surgery. Then possibly drop the Blue Cross Blue Shield if Il (that is through my husband’s employer) until after the surgery, picking it up again during the next open enrollment (I have not yet verified that is possible but I believe it to be).  The rep encouraged me to have my endocrinologist sending in some paperwork asking for an authorization, and she hinted that with the co-morbidity list being so short without wiggle room it meant they would almost hsve to allow other syndromes/disorders in...?).  The criteria may or may not be tougher for the bcbsil than the Tricare East, I cannot yet tell.  I thought perhaps I might need to use both plans until just before the surgery. Then drop the Blue Cross Blue Shield would just think my husband‘s employer until after the surgery. And then pick it up again the next time there was an open enrollment the same year. I feel as if I am plotting battle (beforehand) and so any ammo is useful!