[Obesity surgery: the refusal rate of health care cost reimbursement despite expert opinion].
OBJECTIVE
Surgery is an effective method to treat patients with morbid obesity. However health insurance companies frequently refuse to cover the costs for the procedure despite an existing DRG-code for this operation. Individual medical expertise are necessary to receive reimbursement. In the present study the acceptance of medical expertise to receive cost coverage was analysed in our patients of the years 2000-2003 eligible for obesity surgery.


METHODS
617 medical expertise of patients eligible for obesity surgery in our hospital were reviewed and the acceptance rate was evaluated. Parameters such as body mass index, personal medical history, diets, comorbidity and prognosis were included. Expertise were submitted to the health care insurance companies and in case of acceptance the operation was performed.


RESULTS
The average age of our patients was 39.1 +/- 11.2 years, 72.1% were female, 27.9% male. The average BMI was 47.5 +/- 7.4 kg/m2. There was a high incidence of comorbidity in these patients (58.7% arterial hypertension, 38.6% diabetes mellitus, 95.8% dyspnoea, 96.1% arthropathy, 89.0% psychosocial disorders). The difference between accepted and non-accepted regarding these secondary complications was not significant. 209 patients (33.8%) were operated. 14 patients of these paid the costs themselves. Only in 195 cases (31.6%) the health care insurance company covered the costs for the operation.


CONCLUSIONS
The high number of refusals of medical expertise is not justified in view of the strict criteria for indication, the high frequency of comorbidity and the good results after the operation.
Gärtner
D
D
Klinik für Allgemein-, Viszeral- und Unfallchirurgie, Krankenhaus Bad Cannstatt, Klinikum Stuttgart, Stuttgart.
Hoyer
M
M
Hornung
A
A
Andus
T
T
Bischoff
S
S
Hesse
U
U
D000328:Adult; D050110:Bariatric Surgery / Q000191:economics*; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000453:epidemiology; D050171:Dyslipidemias / Q000453:epidemiology; D004417:Dyspnea / Q000453:epidemiology; D005234:Fatty Liver / Q000453:epidemiology; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D006973:Hypertension / Q000453:epidemiology; D007349:Insurance, Health, Reimbursement / Q000706:statistics & numerical data*; D007592:Joint Diseases / Q000453:epidemiology; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology; D009767:Obesity, Morbid / Q000191:economics / Q000453:epidemiology / Q000601:surgery*; D017410:Practice Guidelines as Topic; D011379:Prognosis; D012189:Retrospective Studies