I don't see anything about a six month nutrition. Keeping my fingers and toes crossed it goes smoothly, I have my Surgeon Consultation on January 10th. I cannot wait to get this weight off for good, my BMI is 48
Bariatric Surgery: Clinical Policy (Effective 1/01/2014)
©1996
-
201
4
, Oxford Health Plans, LLC
2
Note:
Gastric electrical stimulation with an implantable gastric stimulator (IGS) for the treatment
of obesity is addressed in this polic
y. For information regarding other indications, refer to
Gastrointestinal Motility Disorders, Diagnosis and Treatment.
COVERAGE RATIONALE
Required Documentation for Medical Director Review:
•
Office notes including medical history and/or a letter of medical necessity.
Bariatric surgery, as a primary treatment for weight loss
is medically necessary for the following:
1.
Class III obesity (BMI
≥
40 kg/m2)
;
2.
Class II obesity (BMI 35
-
39.9 kg/m2) in the presence of one or more of the following co
-
morbidities:
o
Type 2 diabetes
o
Cardiovascular disease (e.g., stroke, myocardial infarction, ,
poorly contro
lled
hypertension
(systolic blood pressure
greater than 140 mm Hg or diastolic blood
pressure 90 mm Hg or greater, despite pharmacotherapy)
o
History of coronary artery disease with a surgical intervention such as
cardiopulmonary bypass or percutaneous tran
sluminal coronary angioplasty
o
C
ardiopulmonary problems (e.g.,
documented obstructive
sleep apnea
(OSA)
confirmed on polysomnography with an AHI or RDI of
≥30 (as defined by AASM Task
Force. Sleep. 1999; 22: 667
-
89)
o
History of cardiomyopathy