North Texas is a hotbed for weight-loss surgeries, yet many candidates for the procedure complain it's still too difficult to get health insurers to pay.

By one doctor's informal calculations, Dallas is the country's No. 1 market for weight-loss surgeries. It's nearly impossible to sit through a 30-minute midday TV program or sift through a newspaper without being pitched an opportunity to transform your body. Industry observers say the market here is supported by a high concentration of bariatric surgeons and one of the nation's worst rates of obesity-related diseases.

Texas ranks in the top quarter of the country for percentage of residents with Type 2 diabetes, one of the most common and deadly obesity-related diseases, according to the U.S. Centers for Disease Control and Prevention. Within the state, Dallas fares worse than other big cities. Diabetes patients see Dallas doctors nearly twice as often as they do in Houston, according to a study by Pennsylvania researcher SDI Health LLC.

Some, like Terry Johnson, 45, of Burleson, say they are denied coverage for surgery because of unfair prerequisites or an outright unwillingness to pay. He wants weight-loss surgery because obesity has made him sickly.

Johnson – 260 pounds, 5 feet 11 inches tall, with diabetes, heart disease and high blood pressure – said he has not been able to get the surgery because his health insurer repeatedly denied his requests and he can't afford to pay for it himself.

Johnson's weight has kept him from a good night's sleep, even with a prescribed breathing machine. That has made him prone to sinus infections, colds, bronchitis and voice loss. At night, his wife stays on guard to shake him in case he stops breathing – again.

"She says it sounds like a big freight train," Johnson said.

His doctor, Dr. Nick Nicholson, has grown frustrated with denials for coverage. Nicholson owns the Nicholson Clinic in Plano and is medical director of weight-loss surgery programs at Baylor University Medical Center at Dallas.

He calculated that Dallas ranks No.1 in bariatric surgeries, based on data he has received from national suppliers of weight-loss surgical tools.

"But for every 100 people that come in, less than half will get the surgery," Nicholson said.

Some policies require patients to prove they've tried dieting, exercise, medication and psychotherapy, but many of those policies do not pay for the prerequisites, Nicholson said. In addition, submitting the correct paperwork to prove requirements are met can take months or longer if it's lost in the shuffle, Nicholson said.

A quarter of patients considering bariatric surgery are denied insurance coverage three times before getting approval, and about 60 percent report their health worsened during this waiting period, according to an online Harris Interactive survey conducted in May 2008 of 280 surgeons and 400 weight-loss surgery patients. (The American Society for Metabolic & Bariatric Surgery, which has a financial interest in doing more surgeries, funded the survey.)

Documentation

Blue Cross Blue Shield of Texas, the state's largest health insurer, requires a body mass index of 40 or more. It will OK a surgery with a BMI of 35 as long as the patient has two of the following: hypertension, diabetes, coronary heart disease, sleep apnea, osteoarthritis or dyslipidemia, a blood condition.

In addition, it requires documentation that the patient has stopped growing taller and has completed an evaluation from a licensed counselor, psychologist or psychiatrist within 12 months.

"Practically speaking, we'd prefer to intervene well before a member reaches the point where bariatric surgery is an option," said Dr. Eduardo Sanchez, vice president and chief medical officer of Blue Cross Blue Shield of Texas.

"At that point, a lot of ground has already been lost, and no matter which treatment is chosen, the person will have experienced preventable disease and distress, and it will be very expensive to treat the patient."

Obesity costs the nation more than $75 billion a year and Texas more than $5 billion a year, according to the U.S. Centers for Disease Control and Prevention, which looked at direct medical costs linked to obesity.

Patients and surgeons, however, argue that the cost of surgery – in Johnson's case, $12,000 – more than justifies the long-term cost of rebandaging obesity-related ailments.

"They know I've been to the doctor for all these other illnesses," said Johnson, who would like to get down to 180 pounds. "They have to know, because they're paying the bill."

Employers' Option

To be sure, insurers may not be to blame if they offer weight-loss surgery but the employer rejects the coverage option for workers. Most large employers in Dallas are self-insured and typically use an insurance carrier as an administrator.

The time it takes for payback also may discourage insurers from approving surgeries, Nicholson said.

"Insurance companies save money on weight-loss surgery but don't want to pay for it because the average member retention rate is lower than the time it takes to save money," Nicholson said.

If an employee receives the surgery and soon afterward finds a new job, the insurer misses out on the employee's better health and lower medical claims.

That logic, however, is debatable. A study in the September issue of The American Journal of Managed Care said insurers recover their costs for bariatric surgery in two to four years, depending on the type of surgery performed.

Across the board, insurers are routinely updating their guidelines and approving more weight-loss surgeries as the procdures become safer.

Aetna Inc. has approved 40 percent more weight-loss surgeries every year – 4,200 in 2006, 6,000 in 2007 and 8,500 in 2008. Numbers for 2009 have not been calculated but are expected to also be up 40 percent, said Aetna spokeswoman Anjie Coplin.

John Baker, president of the American Society for Metabolic & Bariatric Surgery, said insurers have eased their prerequisites to surgery. Blue Cross Blue Shield of Texas used to require six months of medical supervision before approving the surgery but has changed it to three months, Baker said.

"I applaud them for making the treatment decisions they have been making," Baker said. Baker said the next step is to get insurers to pay for follow-up care. He said he has a dietitian in his office as a benefit to patients because many insurers won't cover them.