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Tuesday January 22 10:39 AM EST
By ABCNEWS.com
Teenage twins are battling with their health insurers for obesity surgery.
Like many overweight students, fraternal twins Tanya and Trisha Hence have gotten used to the taunts of their classmates. Both are morbidly obese.
But recently the 18-year-old high school seniors from Oklahoma City have been in a bigger fight: trying to get their health insurers to provide coverage for weight loss surgery that their mother believes will save their lives.
Tanya, who weighs 425 pounds, has developed a pinched nerve in her back and walks with a cane. Both she and Trisha, who weighs 380 pounds, suffer from diabetes, high blood pressure and high cholesterol.
If the girls were anorexic, they'd be able to get medical coverage for treatment, but Medicaid is reluctant to cover patients when the scales tip the other way, the girls' mother, Tina Chauvin, said. Each of the girls hopes that gastric bypass surgery will help them drop 200 pounds.
Doctors at the Physicians Hospital of Oklahoma said they would do the surgery for free. But the twins are not alone in their problem with getting coverage for this type of surgery.
Not a Quick Fix
Gastric bypass surgery blocks most of the stomach by either stapling part of the stomach closed, or by creating a small stomach pouch that serves as a reservoir and connects directly to the intestine.
If there are no complications, patients can return to their daily lives, eating very small amounts of food, within six weeks after the surgery. Since the surgery reduces stomach size, patients will begin losing weight immediately.
In some instances, however, there can be troublesome side effects including vomiting, explosive diarrhea, and cramping. More serious complications include chronic malnutrition, osteoporosis, infections and intestinal leaks.
In South Carolina, lawmakers are considering a plan that would mandate that insurers make coverage for weight loss surgery available.
Most weight loss experts recognize the need for obesity surgery in extreme cases where a patient's health is at great risk because of their weight. But as America's obesity problem grows, physicians and insurers worry that some obese patients will pursue weight loss surgery as a quick fix.
Health experts also warn physicians to be firm with obese patients, especially young ones considering weight loss surgery.
"At a young age, every other attempt should be made as an alternative to surgery," Wayne Askew, a professor and director of food and nutrition at the University of Utah, told ABCNEWS.com. "Otherwise, [the surgery] would encourage a lifestyle that we don't want to promote."
The twins' doctor has deemed the surgery to be the only option left, however. The girls have tried other weight loss methods, and now they both suffer from diabetes, high blood pressure and high cholesterol — potentially life-threatening conditions related to their obesity.
Because of unusual cases like this, states and health management organizations must consider requests to pay for weight-loss surgery on a case-by-case basis, Askew said.
No Funding For Diet Plans
Age aside, obese patients should try less invasive alternatives first. Diet and exercise should be the first level of attack. The second might be something like getting a prescription for appetite control drugs under the care of the physician.
Only after climbing those two tiers should patients undergo obesity surgery, Askew said.
In an odd twist, though, most insurers who cover obesity treatments do not cover nonsurgical treatments, said Madelyn Fernstrom, director of the University of Pittsburgh's Health System Weight Management Center. Some health insurers will cover 50 percent to 100 percent of the costs for obesity surgery, but those same groups won't kick in a cent for patients who want to enroll in weight loss programs like Weight Watchers.
"The reimbursement issue opens a whole can of worms," Fernstrom told ABCNEWS.com.
The National Institutes of Health (news - web sites) has set out medical guidelines for obesity surgery, but insurers vary widely on how they interpret those guidelines.
"In our system, we are also surprised with some of the denials, but we resubmit with requested documentation," Fernstrom said. "The demand for this surgery is increasing, and the insurance companies are feeling more pressure."
What's Your BMI?
Group Health Cooperative, an HMO based in Seattle, provides coverage for obesity surgery, though it does not do so for those who have Medicaid, because the state of Washington does not pay for the procedure, said Dr. Hugh Straley, the group's associate medical director.
Group Health feels comfortable with covering the procedure is because it has its own doctors on staff, ensuring that the procedure is done well and for just cause, Straley said.
"We don't take it lightly," Straley said. "It's risky, and the long-term results are not well-established." Group Health performs about 40 to 50 such surgeries a year.
In order to be covered for the operation, under Group Health, a person must have a body mass index greater than 50, meaning that they are "severely, morbidly obese." BMI is a mathematical formula that measures patient's weight to height ratio, and it is used by doctors to calculate obesity. A BMI between 25 and 30 is defined as overweight. A BMI of 30 or more is obese.
If a patient in Group Health has BMI that's less than 50, they are only eligible for coverage if they have other weight-related health problems, such as arthritis, diabetes or swelling of the legs. For those with BMIs between 35 and 39, the operation is performed if the patient is suffering from sleep apnea or another poorly controlled condition. But in all cases, there should be evidence that the patient has attempted a medically supervised weight loss program and failed.
Other health plans are reluctant to cover the surgery because they might not be so sure that the patient has gone through all the hoops before resorting to surgery.
"There is concern that this is seen as a first resort, rather than a last resort," Straley said.
By ABCNEWS.com
Teenage twins are battling with their health insurers for obesity surgery.
Like many overweight students, fraternal twins Tanya and Trisha Hence have gotten used to the taunts of their classmates. Both are morbidly obese.
But recently the 18-year-old high school seniors from Oklahoma City have been in a bigger fight: trying to get their health insurers to provide coverage for weight loss surgery that their mother believes will save their lives.
Tanya, who weighs 425 pounds, has developed a pinched nerve in her back and walks with a cane. Both she and Trisha, who weighs 380 pounds, suffer from diabetes, high blood pressure and high cholesterol.
If the girls were anorexic, they'd be able to get medical coverage for treatment, but Medicaid is reluctant to cover patients when the scales tip the other way, the girls' mother, Tina Chauvin, said. Each of the girls hopes that gastric bypass surgery will help them drop 200 pounds.
Doctors at the Physicians Hospital of Oklahoma said they would do the surgery for free. But the twins are not alone in their problem with getting coverage for this type of surgery.
Not a Quick Fix
Gastric bypass surgery blocks most of the stomach by either stapling part of the stomach closed, or by creating a small stomach pouch that serves as a reservoir and connects directly to the intestine.
If there are no complications, patients can return to their daily lives, eating very small amounts of food, within six weeks after the surgery. Since the surgery reduces stomach size, patients will begin losing weight immediately.
In some instances, however, there can be troublesome side effects including vomiting, explosive diarrhea, and cramping. More serious complications include chronic malnutrition, osteoporosis, infections and intestinal leaks.
In South Carolina, lawmakers are considering a plan that would mandate that insurers make coverage for weight loss surgery available.
Most weight loss experts recognize the need for obesity surgery in extreme cases where a patient's health is at great risk because of their weight. But as America's obesity problem grows, physicians and insurers worry that some obese patients will pursue weight loss surgery as a quick fix.
Health experts also warn physicians to be firm with obese patients, especially young ones considering weight loss surgery.
"At a young age, every other attempt should be made as an alternative to surgery," Wayne Askew, a professor and director of food and nutrition at the University of Utah, told ABCNEWS.com. "Otherwise, [the surgery] would encourage a lifestyle that we don't want to promote."
The twins' doctor has deemed the surgery to be the only option left, however. The girls have tried other weight loss methods, and now they both suffer from diabetes, high blood pressure and high cholesterol — potentially life-threatening conditions related to their obesity.
Because of unusual cases like this, states and health management organizations must consider requests to pay for weight-loss surgery on a case-by-case basis, Askew said.
No Funding For Diet Plans
Age aside, obese patients should try less invasive alternatives first. Diet and exercise should be the first level of attack. The second might be something like getting a prescription for appetite control drugs under the care of the physician.
Only after climbing those two tiers should patients undergo obesity surgery, Askew said.
In an odd twist, though, most insurers who cover obesity treatments do not cover nonsurgical treatments, said Madelyn Fernstrom, director of the University of Pittsburgh's Health System Weight Management Center. Some health insurers will cover 50 percent to 100 percent of the costs for obesity surgery, but those same groups won't kick in a cent for patients who want to enroll in weight loss programs like Weight Watchers.
"The reimbursement issue opens a whole can of worms," Fernstrom told ABCNEWS.com.
The National Institutes of Health (news - web sites) has set out medical guidelines for obesity surgery, but insurers vary widely on how they interpret those guidelines.
"In our system, we are also surprised with some of the denials, but we resubmit with requested documentation," Fernstrom said. "The demand for this surgery is increasing, and the insurance companies are feeling more pressure."
What's Your BMI?
Group Health Cooperative, an HMO based in Seattle, provides coverage for obesity surgery, though it does not do so for those who have Medicaid, because the state of Washington does not pay for the procedure, said Dr. Hugh Straley, the group's associate medical director.
Group Health feels comfortable with covering the procedure is because it has its own doctors on staff, ensuring that the procedure is done well and for just cause, Straley said.
"We don't take it lightly," Straley said. "It's risky, and the long-term results are not well-established." Group Health performs about 40 to 50 such surgeries a year.
In order to be covered for the operation, under Group Health, a person must have a body mass index greater than 50, meaning that they are "severely, morbidly obese." BMI is a mathematical formula that measures patient's weight to height ratio, and it is used by doctors to calculate obesity. A BMI between 25 and 30 is defined as overweight. A BMI of 30 or more is obese.
If a patient in Group Health has BMI that's less than 50, they are only eligible for coverage if they have other weight-related health problems, such as arthritis, diabetes or swelling of the legs. For those with BMIs between 35 and 39, the operation is performed if the patient is suffering from sleep apnea or another poorly controlled condition. But in all cases, there should be evidence that the patient has attempted a medically supervised weight loss program and failed.
Other health plans are reluctant to cover the surgery because they might not be so sure that the patient has gone through all the hoops before resorting to surgery.
"There is concern that this is seen as a first resort, rather than a last resort," Straley said.
