I also have BCBS of MN. I started my journey in January 2013 and will be submitted for approval next week. My policy states; Patient must have a BMI>40, patients with a BMI 35-40 will be considered when there is documentation of a co-morbid condition.
2. The condition of morbid obesity must be of at least two years
duration. Because attempts to lose weight over this two-year
time period may cause the patient’s BMI to fluctuate around
the required levels, the two-year time period will not
necessarily start over, or be prolonged, but will be reviewed
on a case-by-case basis.
AND
3. Over the last year prior to surgery, the patient has actively
participated in a structured, nonsurgical weight loss program
(i.e.,, a program that provides diet, exercise, and behavior
modification strategies through individual or group
counseling) , for a total of six months with failure to achieve
weight loss goals or maintain weight loss. Participation in
one of these programs must be at least 3 consecutive
months in duration. Participation must be monitored by the
primary care physician providing medical oversight for the
patient and must be documented in the medical record
AND
4. The patient must be evaluated preoperatively by an eligible
licensed Mental Health Professional1 to ensure the absence
of significant psychopathology that would hinder the ability of
an individual to understand the procedure and comply with
medical/surgical recommendations
AND
5. The physician requesting authorization for the surgery must
confirm that the patient’s treatment plan includes a surgical
preparatory program addressing all the following
components in order to improve outcomes related to the
surgery and to establish the member's ability to comply with
post-operative medical care and dietary restrictions:
a. Pre-operative and post-operative dietary plan; AND
b. Behavior modification strategies; AND
c. Counseling and instruction on exercise and increased
physical activity; AND
d. Ongoing support for lifestyle changes necessary to
make and maintain appropriate choices that will reduce
health risk factors and improve overall health.
I know every policy is different but this is what my coordinator/insurance specialist has for BCBS of MN.
Good Luck!
