Insurance Carrier Medically Supervised Diet Diet History Notes Aetna 6 Months OR 3 Months 2 Years 6 Months-nutrition and exercise OR 3 Months-dietician, primary care physician & exercise regimen Blue Care Network 6 Consecutive Months (180 days) 2 Years BMI ≥50 criteria for diet waived Blue Care Network Advantage Documented unsuccessful with medical treatment for obesity 2 Years At least one co-morbidity related to obesity Blue Cross Complete (Medicaid ***) 6 Months Current (Greater than or equal to 6 months) BCBS MI & BCBS Messa 6 Consecutive Months (180 days) 4 Years BMI ≥50 criteria for diet waived BCBS Out of State Contact Insurance Plan 2 Years Champ VA Failed attempts-non surgical medical treatment 2 Years Cigna 3 Consecutive Months 1 Year Cofinity Contact Insurance Plan Connect Care 3 Months 2 Years Health Alliance Plan (HAP) 6 Months 2 Years BMI ≥50 criteria for diet waived HealthPlus (*** and PPO) 6 Months 2 Years (Unless deemed High Risk with co-morbid diagnosis) Medicaid (Straight) What efforts have been taken for weight reduction 2 Years Documented medical diagnosis that may be life threatening as result of obesity Medicare Documented unsuccessful with medical treatment for obesity 2 Years At least one co-morbidity related to obesity McLaren Health Plan 6 Consecutive Months. Food & Exercise Journal Current Showing a consistent weight loss with no weight gain Molina-Medicaid 12 Consecutive Months 2 Years Showing a consistent weight loss with no weight gain Priority Health Commercial 6 Months with 12 Months (waived if BMI is > 50) 1 Year Accept commercial, PPO & Medicare only (Not contracted with Medicaid Priority Hlth) Total Health Care-Medicaid 12 Consecutive Months 1-2 Years Counseling with Psychiatrist 6-9 months and 6-9 months nutritional counseling Tricare (Standard & Prime) Prime ***-6 Months Standard-Not Specific 1 Year Sleeve is now covered effective 9/2014 United Healthcare Commercial 6 Months (not specific with consecutive) Current Check Benefits. We do not accept Optum Health through United Health Care United Healthcare Great Lakes-Medicaid 12 Consecutive Months 2 Years Showing a weight loss and no weight gain

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Edited February 9, 201610 yr by Tosha-248

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