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Monday, April 30, 2007

Tufts Health Plan loosens restrictions on obesity surgery

By Elizabeth Cooney, Globe Correspondent

Tufts Health Plan has quietly loosened its restrictions on weight-loss surgery, expanding who can get insurance coverage for the operations and shrinking how much time patients must first spend in a counseling program.

The restrictions were criticized by the state Department of Public Health, patients and surgeons even before they went into effect in March.

In a statement issued yesterday in response to questions about its new policy, Tufts said it was committed to offering its members the best chance for long-term success.

"Working most closely with bariatric surgeons at Tufts-New England Medical Center, we jointly agreed to guidelines for the coverage of bariatric surgery," the statement said.

Tufts spokeswoman Catherine Grant said the plan would not elaborate on the reasons for the change.

The revised rules, effective as of April 16, appear to address some of the concerns raised by Nancy Ridley, associate public health commissioner, who in February sent a letter to Tufts president and CEO James Roosevelt Jr. saying the restrictions were "contrary to evidence-based guidelines" that the department had crafted for obesity surgery. She warned him that the agency could review denials of coverage.

Under the revised rules, Tufts will pay for obesity surgery for members with a body mass index above 35 if they also have diabetes, hypertension or sleep apnea that requires medical treatment. Under the original rules, the minimum BMI for such patients was 40.

The health plan also dropped limits on the types of obesity surgery patients could qualify for. Now patients eligible for coverage can undergo either laparoscopic gastric banding or gastric bypass surgery.

Before surgery, members now must join the health plan's lifestyle modification program, called iCanChange, for six months, down from 12 months under the original rules. They can continue the behavioral program for 12 months if they wish, rather than go on to surgery, the plan said.

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