Gastric
Bypass
Insurance
Guidelines
AETNA
GUIDELINES
Aetna
only
covers
Roux-en-Y
gastric
bypass.
They
consider
LAP BAND
as
experimental
and will
only
cover it
in
specific
individual
cases.
Required
Documentation:
-
Presence
of
morbid
obesity
that
has
persisted
for
at
least
5
years,
defined
as
either:
-
Body
mass
index
(BMI)*
exceeding
40;
or
-
BMI*
greater
than
35
in
conjunction
with
the
following
severe
co-morbidities
that
are
likely
to
reduce
life
expectancy:
- Coronary heart disease; or
- Type 2 diabetes mellitus; or
- Obstructive sleep apnea; or
- Hypertension (BP> 140 mmHg systolic and /or 90 mmHg diastolic)
NOTE: A
PHYSICIAN’S
SUMMARY
LETTER
IS NOT
SUFFICIENT
DOCUMENTATION
-
Patient
has
completed
growth
(18
years
of
age
or
documentation
of
completion
of
bone
growth);
-
Clinical
records
documenting
the
medical/dietary
therapies
(within
two
years
prior
to
the
surgery)
by
an
attending
physician
who
supervised
the
member’s
participation.
- Documentation of five year weight history; AND
- Documentation of any medication that was prescribed by a physician to assist in weight loss; AND
- Co-morbidities and cardiac risk factors such as smoking, hypertension, family history, etc.; AND
- Surgical consult report indicating need for surgery.
Documentation
of
pre-operative
evaluation
and
clearance
for
members
who have
a
history
of
severe
psychiatric
disturbances
or who
are
currently
under
the care
of a
psychologist
/
psychiatrist
or who
are on
psychotropic
medications.
Aetna is
denying
our
request
for
obesity
surgery
if this
documentation
is not
provided,
therefore
we will
not
contact
your
insurance
company
until we
receive
this
documentation.
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BLUE
CROSS
BLUE
SHIELD
GUIDELINES
Required
Documentation:
Presence
of
morbid
obesity
that has
persisted
for at
least 5
years,
defined
as
either:
-
Body
mass
index
(BMI)*
exceeding
40
OR
-
BMI*
greater
than
35
in
conjunction
with
the
following
severe
co-morbidities
that
are
likely
to
reduce
life
expectancy:
- Coronary heart disease; or
- Type 2 diabetes mellitus; or
- Obstructive sleep apnea; or
- Hypertension (BP> 140 mmHg systolic and /or 90 mmHg diastolic)
-
Clinical
records
documenting
the
medical/dietary
therapies
by
an
attending
physician
who
supervised
the
member’s
participation.
-
History
and
physical
with
documented
five
year
history
of
morbid
obesity
-
Documentation
of
failure
of
12
consecutive
months’
medically
supervised
non-surgical
methods
of
weight
reduction
by
an
MD,
DO
or
nurse
practitioner
–
that
includes
nutritional,
medication
or
maintenance
therapy,
behavior
modification,
exercise
or
increase
of
activity
-
Initial
evaluation
-
Psych
evaluation
-
Documentation
of
willingness
to
comply
with
preoperative
and
postoperative
treatment
plans.
These
are
general
guidelines.
Since we
do not
know if
your
particular
Blue
Cross
Blue
Shield
policy
is
requiring
all of
this
information,
we will
submit a
letter
of
medical
necessity
and
verify
that
this is
the
required
information.
However,
since it
is
likely
that
they
will
want
this
information,
you can
be
working
on
gathering
it now.
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CIGNA
GUIDELINES
Required
Documentation:
BMI
of 40 or
35 and
higher
with one
or more
co-morbidities
for at
least
one year
with all
of the
following
criteria:
-
At
least
18
years
of
age
and/or
full
skeletal
growth.
-
Documentation
of
a
26
consecutive
week
(6
months)
professionally
supervised
weight
loss
program
within
the
last
two
years.
This
could
include
programs
such
as
Weight
Watchers,
or
a
program
by
a
physician.
-
Internal
Medical
clearance
to
include
a
history
and
physical,
height,
weight,
body
frame,
blood
pressure
readings,
and
lab
testing.
This
can
be
done
through
your
primary
care
physician.
-
A
consultation
from
a
dietician.
-
A
psychological
evaluation.
Cigna
is
denying
our
request
for
obesity
surgery
if this
documentation
is not
provided;
therefore
we will
not
contact
your
insurance
company
until we
receive
this
documentation.
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FIRST
HEALTH
GUIDELINES
Required
Documentation:
-
History
and
Physical
from
your
primary
care
physician
documenting
any
co-morbid
conditions.
-
A
psychological
evaluation.
First
Health
is
denying
our
request
for
obesity
surgery
if this
documentation
is not
provided,
therefore
we will
not
contact
your
insurance
company
until we
receive
this
documentation.
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GREAT
WEST
HEALTHCARE
Required
Documentation:
-
Presence
of
morbid
obesity
with
a
Body
mass
index
(BMI)*
of
40
or
greater
than
35
with
a
significant
co-morbid
condition
such
as:
A. Life threatening cardiopulmonary disease; or
B. Disabling degenerative joint disease of the lower extremities; or
C. Type 2 diabetes mellitus; or
D. Obesity related pulmonary hypertension
E. Clinically significant asthma; or
F. Obesity related cardiomyopathy; or
G. Moderate to severe gastric esophageal reflux disease; or
H. Uncontrolled hypertension.
-
Minimum
age
of
18.
-
Weight
management
history
which
includes
all
of
the
following:
- A. Obesity duration greater than five years.
- B. Participation in a weight loss program for six months (within the last two years) with chart notes that include documentation of all of the following:
- a. Dietary program for weight loss which consists of a very low calorie diet program (i.e. Optifast), Nutri-Systems, Jenny Craig or Weight Watchers which includes monthly weigh-ins and nutritional analysis.
- b. Monthly clinical encounters with a healthcare professional who does not perform weight loss surgery.
- c. Increased activity/exercise regimen unless contraindicated.
- d. Behavior modification program supervised by a qualified professional to reinforce dietary therapy and increased physical activity.
- e. Weight loss management history includes pharmacotherapy with physician prescribed weight loss drugs or documentation of why pharmacotherapy was not tried.
-
Multidisciplinary
pre-operative
evaluation
that
includes
all
the
following:
A.
Nutritional
evaluation
by
a
licensed
nutritionist,
dietitian
or
physician.
B.
Medical
evaluation
that
addresses
endocrine
disorder
or
other
cause
of
excessive
weight
gain
that
might
be
reversible
without
surgery
C.
Psychological
evaluation
by
a
licensed
mental
healthcare
professional
that
addresses
the
following:
- a. Absence of problems related to alcohol or substance abuse for at least one year.
- b. Absence of major psychotic or disabling mental health diagnosis including mania,
- schizophrenia, et. al.
- c. Absence of compulsive or obsessive-compulsive disorder.
- d. Eating disorders (i.e. bulimia)
- e. Likelihood of willingness to comply with post-op requirements.
-
Commitment
to
planned
post-op
multidisciplinary
approach
that
includes
on-going
regular
meetings,
at
least
monthly
for
first
six
months
post-op,
with
psychiatric
or
psychological
support/consultation
and
dietician
or
nutritionist
support/consultation
and
exercise.
Great-West
will
deny our
request
for
obesity
surgery
if this
documentation
is not
provided,
therefore
we will
not
contact
your
insurance
company
until we
receive
this
documentation.
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ONE
HEALTH
PLAN
GUIDELINES
Required
Documentation:
-
Documentation
of
being
100
or
more
pounds
overweight
for
the
past
3
years
-
You
must
be
between
the
ages
of
25
to
55
-
A
consultation
from
a
dietician
-
A
psychological/psychiatric
evaluation
-
You
must
not
have
had
an
alcohol
habit
in
the
past
year
-
You
must
provide
documentation
of
physician
supervised
weight
loss
attempts
in
the
past
3
years
One
Health
Plan is
denying
our
request
for
obesity
surgery
if this
documentation
is not
provided,
therefore
we will
not
contact
your
insurance
company
until we
receive
this
documentation.
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UNICARE
GUIDELINES
Required
Documentation:
-
Internal
Medicine
clearance
(can
be
obtained
through
your
primary
care
physician)
-
Thyroid
panel
to
include
TSH
level
(can
be
obtained
through
your
primary
care
-
physician)
-
A
psychological/psychiatric
evaluation
Unicare
is
denying
our
request
for
obesity
surgery
if this
documentation
is not
provided,
therefore
we will
not
contact
your
insurance
company
until we
receive
this
documentation.
RETURN
TO TOP
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