IRO Bariatric Medical Reviews - Medical Review Criteria for Bariatric Surgery

Losing weight is the #1 New Year's resolution in America. However, many people believe they are so overweight that bariatric surgery may be the only option. And they may be right. During the past 20 years, there has been a dramatic increase in obesity in the U.S. Currently, more than 44 million Americans are considered obese. In 1995, just 20,000 weight-loss operations were performed. Last year, physicians performed 103,000 bariatric surgeries, with more than 144,000 bariatric surgeries projected in 2004.

For insurance companies, bariatric surgery numbers are alarming. Bariatric surgeries average $30,000 each and sometimes more. And now Medicare has changed obesity to be classified as an illness. This change often results in gastric bypass surgery being classified as medically necessary and means health insurance companies may be expected to pay for claims that, in the past, would not have been covered.

To ensure the medical necessity of the procedure, many insurance companies are turning to independent review organizations (IROs) for bariatric medical reviews. Independent Review Organizations (IROs) offer arms-length medical reviews of difficult or questionable bariatric cases and help insurance companies determine whether or not the bariatric procedures are medically necessary. These medical reviews are done by a panel of like specialists, or physician peers, and are based on proven medical facts.

"Health insurance payers really do care for their customers and want them to get the treatments they need to maintain a healthy lifestyle,' said Dr. Skip Freedman, medical director at AllMed Healthcare Management, a leading Independent Medical Review (IRO) Organization. "Our role is to help payers make sure they aren't paying for procedures that are not needed or might have better results with less expensive treatments.'

According to Dr. Freedman, the main questions that need to be asked in a medical review to determine whether bariatric surgery is truly required include:

• Is the person suffering from morbid obesity (BMI over 40)?
• Has the patient passed/failed one or more non-surgical, medically supervised weight loss programs?
• Does the patient have a medical illness related to obesity?
• Is the patient willing to participate in a pre-surgery weight loss effort?
• Can the patient make the lifestyle adjustment necessary to sustain weight loss?

Only by answering these questions in a medical review can one determine whether a claim is medically necessary or simply a cosmetic, optional procedure. More information on bariatric surgery and IROs can be found on AllMed's Web site at http://www.allmedmd.com.

About AllMed:
Allmed reviews claims for issues of medical necessity, standard of care, experimental / investigational, hospital quality management, code unbundling, fraud, and other issues that affect healthcare decision-making.