I was finally able to get some clarification regarding my coverage. Knowing what to expect puts me at ease.
Gastric Bypass Surgery (Bariatric Surgery) is covered only if specific medical criteria are met:
Bariatric surgery may be indicated for patients 18 to 60 years of age. Requests for bariatric surgery for patients less than 18 years of age should include documentation that the primary care physician has addressed the risk of surgery on future growth, the patient's maturity level and the patient’s ability to understand the procedure and comply with postoperative instructions, as well as the adequacy of family support. Patients above 60 years of age may be considered if it is documented in the medical record that the patient’s physiologic age and co-morbid condition(s) result in a positive risk/benefit ratio. • The patient has been clinically evaluated by an MD or DO. The physician has documented failure of non-surgical management including a structured, professionally supervised (physician or non-physician) weight loss program for a minimum of six consecutive months within the last four years prior to the recommendation for bariatric surgery. The six consecutive month weight loss program listed above is waived for super morbidly obese individuals who have a BMI ≥50. Documentation should include periodic weights, dietary therapy and physical exercise, as well as behavioral therapy, counseling and pharmacotherapy, as indicated. • Documentation that the PCP and the patient have a good understanding of the risks involved and reasonable expectations that the patient will be compliant with all postsurgical requirements. • A psychological evaluation must be performed as a pre-surgical assessment by a contracted mental health professional in order to establish the patient’s emotional stability, ability to comprehend the risk of surgery and to give informed consent, and ability to cope with expected post-surgical lifestyle changes and limitations. Such psychological consultations may include one unit total of psychological testing for purposes of personality assessment (e.g., the MMPI-2 or adolescent version, the MMPI-A). • The physician needs to be aware and follow-up with individuals who have had gastric surgery for any long-term complications. • In cases where a revision of the original procedure is planned, documentation of all of the following is required: - Date and type of previous procedure - The factor(s) that precipitated failure - Any complications from the previous procedure that mandate (necessitate) the takedown - If the indication for the revision is a failure of the patient to lose a desired amount of 51 weight then the patient must meet all of the initial preoperative criteria. Note: The following surgical procedures are considered experimental/investigational because their safety and/or effectiveness have not been proven: • Loop gastric bypass gastroplasty - also known as mini-gastric bypass • Stomach stapling Endoscopic procedures to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches are considered experimental/investigational.
