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Last issue, we asked which of you consider first-line for long-term cardiovascular risk reduction when a patient is eligible for both bariatric surgery and a GLP-1. That's an evidence question, and reasonable clinicians land in different places on it.
This issue is about a different question, one that isn't really about evidence at all.
The mandate nobody voted on
More of you are telling us that the choice between GLP-1 therapy and surgery isn't being made in the exam room anymore. It's being made by a prior-authorization desk. A growing number of payers now require a documented trial (and often a documented failure) of GLP-1 therapy before they'll authorize a bariatric procedure, regardless of what the surgeon's clinical judgment says about which approach actually fits the patient in front of them.
For some of you, that's not a problem . Maybe, you'd order the GLP-1 trial anyway. For others, it's adding six to twelve months of delay, side effects, and cost to a patient who was already a clear surgical candidate.
Is this converging toward a de facto standard of care, whether or not the data supports it as one?
Is it a cost-containment policy wearing a clinical-guideline costume?
Or is a trial-first approach actually defensible on the evidence, and surgeons are just annoyed at the friction?
We want the real answer from the people actually living this. Not an association position statement.
Do you require a GLP-1 trial before approving a patient for bariatric surgery?
Vote, then send this to the partner in your group who disagrees with you. This is the kind of question where your practice's answer and the practice down the street's answer are probably different. We'd like to know by how much. We'll share the breakdown, including the free-text comments, in the next issue.
Know a colleague who's fighting this exact battle with a payer right now? Forward them this issue — MBS Digest is free, and a recommendation from a peer is worth more than anything we could buy in ad space.
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