Insurance Policy/Criteria

I thought someone might find this helpful. It's the approval guidelines for BC/BS Regence. Even if this isn't your ins. co. it's a good guideline.

Policy/Criteria

1.Gastric bypass using a Roux-en-Y anastomosis with an alimentary limb of 150 cm or less, or adjustable gastric banding, consisting of an adjustable external band placed around the stomach, may be considered medically necessary in the treatment of morbid obesity when all of the following criteria are met: A.BMI greater than or equal to 40 kg/m2; or BMI greater than or equal to 35 kg/m2 with at least two of the following comorbid conditions which have not responded to medical management and which are generally expected to improve as a result of obesity surgical treatment: 1)Hypertension 2)Dyslipidemia 3)Type 2 diabetes 4)Coronary heart disease 5)Sleep apnea B.Documentation of active participation for at least one year in a structured, medically supervised nonsurgical weight reduction program, meeting all of the following criteria: 1)Medical supervision must be provided by an MD, DO, NP, PA or a registered dietitian under the supervision of an MD, DO, NP, or PA; and 2)Participation must occur during at least 12 consecutive months within the 24 months prior to the request for surgery; and 3)Documentation must confirm structured oversight and active participation, including: a.At least four visits over the course of 12 months, occurring approximately once every three months; and b.Assessment and counseling concerning weight, diet, exercise, and behavior modification; and c.Either weight loss or no further weight gain over the course of 12 months. C.Evaluation by a licensed psychologist or psychiatrist documents the absence of significant psychopathology that can limit an individual's understanding of the procedure or ability to comply with medical/surgical recommendations (e.g., active substance abuse, schizophrenia, borderline personality disorder, uncontrolled depression); and D.Documentation of willingness to comply with preoperative and postoperative treatment plans; and E.Age greater than or equal to 18 years.

Surgery for Morbid Obesity