Insurance Guidelines for Gastric Bypass Surgery

AETNA
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.

BLUE CROSS BLUE SHIELD

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.

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.

FIRST HEALTH

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.

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.