Medically Necessary:

Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band® System or the REALIZE™ Adjustable Gastric Band), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria:

1. BMI of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to:
   
   • diabetes mellitus; or
     
   • cardiovascular disease; or
     
   • hypertension; or
     
   • life threatening cardio-pulmonary problems, (e.g., severe sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy); AND
     

[*]The patient must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery; AND

[*]The physician requesting authorization for the surgery must confirm the following:

• The patient's psychiatric profile is such that the patient is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and
  
• The patient's post-operative expectations have been addressed; and
  
• The patient has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and
  
• The patient has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and
  
• The patient has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and
  
• The patient's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and
  
• The patient's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed.
  

Surgical repair following gastric bypass and gastric restrictive procedures is considered medically necessary when there is documentation of a surgical complication related to the original surgery, such as a fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band herniation, or pouch enlargement due to vomiting.

Repeat surgical procedures for revision or conversion to another surgical procedure (that is also considered medically necessary within this document) for inadequate weight loss,* (i.e., unrelated to a surgical complication of a prior procedure) are considered medically necessary when all the following criteria are met:

• The patient continues to meet all the medical necessity criteria for bariatric surgery (see page 1); and
  
• There is documentation of patient compliance with the previously prescribed postoperative dietary and exercise program; and
  
• 2 years following the original surgery, weight loss* is less than 50% of pre-operative excess body weight and weight remains at least 30% over ideal body weight (taken from standard tables for adult weight ranges based on height, body frame, gender and age).
  

Following an initial adjustable banding procedure that met the medically necessary criteria in this document, adjustments to the banding devices are considered medically necessary so long as the adjustment is for a medically necessary purpose, (e.g., to control the rate of weight loss or treat symptoms secondary to gastric restriction).

I have that too but what I am questioning is the apprasail of the attempted weight loss...There is no reference if we need to have a supervised weight loss etc...Do you know if we need that?

I called my insurance today asking the questions. I was told that they decide on a case by case basis. I told her I was worried about having to go on a diet that would waste another 6 months to prove something I already know. She said there is no way of knowing until the surgeon applies. Then BCBS will evaluate and decide what is needed further.

im sure it will all work out for you!

Did you have to go through a lot of hoops to get your surgery approved by insurance?

I went to my family physician this week, got a referal for a surgeon. They told me I needed to call myself to see if the prodecure was covered by my insurance. Anyway, I call today, when I got to the right person I asked, "Is the Lapband prodecure covered?" not one second went by and she snapped out, "No."

I would love to hear what other people had to go through. Now that I've researched the LB, it's my answer I want it more than anything..