Should Insurance Companies Require Structured Attempts at Weight Loss As a Condition for Approval of Weigth Loss Surgery?

Abraham J Frech, MD, Arpan Goel, MD, Tovy H Kamine, MD, Robert A Andrews, MD, Daniel B Jones, MD, Benjamin E Schneider, MD. Beth Israel Deaconess Medical Center/Harvard Medical School

Introduction:
Insurance companies frequently require patients to have participated in structured attempts at weight loss as a prerequisite for weight loss surgery approval. This begs the questions whether such interventions affect surgical weight loss outcomes; and/or does the number of attempts at non-operative weight loss have any effect on outcomes? The aim of our study was to determine if the number of preoperative attempts at weight loss correlated with postoperative success after WLS.

Methods and Procedures:
Between September and December 2010, 108 surveys were collected from postoperative patients weight loss surgery patients at an academic medical center. Patients included in the survey underwent either Roux-en-Y gastric bypass or adjustable gastric band. Of the 108 collected surveys, 14 were excluded as incomplete. The remaining 94 surveys that were complete were analyzed. The patients reported their type of diet and the number of preoperative attempts at weight loss. We divided patients into three groups based upon the number of attempts at weight loss in advance of surgery (Table 1).
Table 1
Groups          Preoperative attempts       Patients
Low                0-3 Attempts                   N = 52
Moderate        4-6 Attempts                   N = 32
High               7+ Attempts                    N = 10

Results:
Time                            Patients      Correlation Coefficient      P value
1 month post op           N = 94           0.22                            0.03
1 year post op              N = 61           0.11                            0.40
2 years post op            N = 40           0.16                            0.34
Table 2: Number of patients at each time point and correlation coefficient and p value between increasing attempts and weight loss (where a correlation coefficient of 1 is a perfect correlation).

At one month following surgery, there was a significant correlation between the number of previous attempts and actual weight loss (correlation coefficient of 0.22, p 0.03). Beyond one month (1 and 2 years), there was no correlation between actual weight loss and the number of prior attempts at dieting.

Conclusion:
While multiple attempts at dieting predicted better weight loss at one month, these differences were not durable. Patients who had dieted once or twice were just as likely to do well at 1 and 2 years as those who dieted more frequently. There is little outcome based justification that an arbitrary number of diets should be required for insurance preauthorization prior to weight loss surgery.