Surgical Treatment of Morbid Obesity
The medical need for this procedure must be established documenting that the enrollee has significant symptoms or functional impairments that cannot be adequately managed with more conservative, less invasive measures. The following criteria are used when considering requests for surgical treatment of morbid obesity:
1. Review of the health plan document to determine whether the procedure is a covered benefit.
2. A statement from the patient’s primary care physician recommending the weight reduction surgery and that there are no contraindications to the proposed procedure, such as liver disease or psychosis.
3. Documentation from the patient’s primary care physician of at least 3 months of an adequate trial of weight reduction techniques within the previous 2 years. This is reviewed to establish that adequate conventional weight loss trials have been attempted and that the patient will able to comply with post-operative regimens. This may or may not include use of prescription drugs for weight loss. In the monthly documentation there must be details of the treatment plan, regular recording of patient’s weight, evidence of regular supervision/counseling by the primary care physician, including a dietary evaluation and evidence of patient compliance with the treatment plan. This criteria is waived if BMI is > than 50.
4. Morbid obesity is established using the following indicators:
· Body Mass Index (BMI) is >40
· Body Mass Index (BMI) is between 35-40 and patient has been diagnosed with a significant life threatening co-morbidity by the primary care physician. Examples of such co-morbidities include Congestive heart failure, Cardiomyopathy, Type 2 diabetes, Obstructive sleep apnea (OSA), Hypertension, Hyperlipidemia, Obesity-hypoventilation syndrome (OHS), Pickwickian syndrome, Nonalcoholic fatty liver disease, Nonalcoholic steatohepatitis, Pseudotumor cerebri, Gastroesophageal reflux disease, Asthma, Venous stasis disease, Severe urinary incontinence, and Debilitating arthritis.
· Asian patients –the BMI criteria may be reduced by 2.5 to account for genotypic differences resulting in higher comorbidities at lower BMIs.
5. In order to rule out the possibility of other treatable causes of the obesity, the enrollee’s primary care physician has determined that organic illness is not causing obesity, as the presence of such diseases may influence of the long-term success of the obesity surgery. Examples of such diseases may include hypothyroidism, Cushing’s disease, hypothalamic lesions, or other endocrine abnormalities.
6. The patient is psychologically stable and able to understand and cope with the potential body image and lifestyle changes which may occur as a result of the proposed surgery, as documented by a written evaluation from a consultant psychiatrist/psychologist.
7. The enrollee is over eighteen (18) years of age.
ConnectCare considers repeat bariatric surgery medically necessary for members whose initial bariatric
surgery was medically necessary and who meet the following criteria:
· Conversion from an adjustable band to another morbid obesity surgical procedure is considered medically necessary for members who have been compliant with a prescribed nutrition and exercise program following the band procedure, and there are complications that cannot be corrected with band manipulation, adjustments, or replacement.
