care first

[Char_in_Md 0]

this is what I found on the carefirst website....does this sound good?

Medical Policy

7.01.036 Obesity and Morbid Obesity

Original MPC Approval: 04/01/98

Last Review: 03/13/2008

Last Revision: 03/13/2008

Description

Description

Obesity is an increase in body weight due to an excessive amount of body fat.

Morbid obesity is also referred to as medically complicated obesity. According to the National Institutes of Health (NIH) Consensus Conference Panel, patients who have serious morbidity directly related to their weight are considered morbidly obese. Some examples of co-morbidities include hypertension, diabetes mellitus or cardiopulmonary conditions. Patients with morbid obesity generally have at least a body mass index* (BMI) of 40 (35 with certain co-morbid conditions).

* BMI = [weight (kilograms) / height (meters) squared]

The goal of bariatric surgery for the treatment of morbid obesity is to restrict stomach capacity, encourage malabsorption or both. Several surgical open and / or laparoscopic procedures have been proposed, including:

• Gastric bypass, in which approximately 90% of the stomach is bypassed and anastomosed (reattached) to the proximal jejunum during an open or laparoscopic procedure. The unused portion of the stomach and intestine is also anastamosed to the jejunum or ileum, via a Roux-en-Y surgical technique. A length of the small intestine may also be bypassed, depending on the procedure (e.g., long or very long Roux-en-Y gastric bypass). NOTE: The Roux-en-Y technique is also used for other gastrointestinal surgeries, unrelated to surgery for morbid obesity.
  
• Gastric stapling (or vertical banded gastroplasty), in which a proximal pouch of 30-60 ml and a one centimeter outlet is created by a vertical row of staples and horizontally placed reinforcing band. This is not the same as gastric banding.
  
• Jejunoileal bypass, any surgical procedure that shunts ingested food from the jejunum into the ileum, thus bypassing a majority of the small intestine.
  
• Biliopancreatic bypass (i.e. Scopinaro procedure), a surgical procedure involving a subtotal gastrectomy to limit food ingestion and a small intestine bypass to divert bile and pancreatic juice into the distal ileum.
  
• Duodenal switch, is a modification of the biliopancreatic bypass.
  
• Sleeve gastrectomy, removal of the fundus portion of the stomach to limit food intake which is performed as part of the biliopancreatic bypass and duodenal switch techniques.
  
• Gastric wrapping, a surgical procedure in which the stomach is folded over on itself and a full stomach wrap of polypropylene mesh is applied, used to limit gastric volume.
  
• Adjustable gastric banding, a surgical procedure which limits food intake by placing a constricting ring around the stomach's top end (fundus). The adjustable gastric band is a surgical device that is laparoscopically applied around the stomach, creating a small gastric pouch, and a calibrated opening to the rest of the stomach.
  
• Gastric balloon (e.g. Garren-Edwards gastric bubble), is an inflatable device placed in the stomach under endoscopic guidance in an attempt to decrease gastric capacity. The device is then filled with normal saline in an attempt to induce early satiety.
  

Policy

Policy

The following surgical treatments for morbid obesity are considered to be medically necessary when specific patient selection criteria are met, as outlined in the Policy Guidelines:

• Adjustable gastric banding (e.g. Lap BAND®)
  
• Gastric bypass
  
• Gastric stapling
  
• Biliopancreatic bypass with duodenal switch
  
• Sleeve gastrectomy, performed either as a stand-alone restrictive procedure, or as a first stage procedure of a planned biliopancreatic bypass with duodenal switch.
  

The following surgical treatments for morbid obesity are considered to be experimental / investigational:

• Jejunoileal bypass, as it does not meet TEC criteria # 2, 3, and 4.
  
• Biliopancreatic bypass (i.e. Scopinaro procedure), as it does not meet TEC criteria # 2, 3 and 4.
  
• Gastric wrapping, as it does not meet TEC criteria # 2 and 3.
  
• Gastric balloon (e.g. Garren-Edwards gastric bubble), as it does not meet TEC criteria # 2, 3 and 4
  

Policy Guidelines

Policy Guidelines

Surgical treatment of morbid obesity is considered to be a viable treatment option in patients who meet allof the following criteria:

Age:

• 18 years old or older and
  

Psychological examination:

• complete a psychological examination to determine readiness and fitness for surgery and necessary postoperative lifestyle changes and
  

Structured diet program:

• Maryland and D.C. plan members only: must complete a structured diet program in the 2-year period that immediately precedes the request for the surgery by participation in either:
  

- one structured diet program for 6 consecutive months or

- two structured diet programs for 3 consecutive months. (can include commonly available diet programs such as Weight Watchers® or Jenny Craig®) and

Weight requirement:

• Maryland and D.C. plan members only: must meet eitherof the following criteria:
  - BMI of 40; or
  - BMI equal to or greater than 35, in combination with one or moreof the following co-morbid conditions:
  hypertension;
  a cardiopulmonary condition;
  sleep apnea;
  diabetes mellitus; or any life threatening or serious medical condition that is weight induced
  
  
• Virginia plan members only: must meet either of the above BMI criteria or the following:
  Weight at least 45.5kg (100 lbs.) above or twice ideal body weight as specified in the
  Metropolitan Life Insurance Tables. (see Tables Below)
  

[Nat0526 0]

I'm a Carefirst BCBS of MD member and I called to get the information about requirements for the surgery and they mentioned everything you posted except for the information about the option to do 2 managed diets for 3mths instead of waiting the full 6mths with one.

I have an appt with a nutritionist on June 9th, 2008 and want to get my ticker started. If I can get the surgery sooner than December, I'm all for it. I'll have to make sure that will work and move forward with that plan.

Thanks for the info,

Nat

[Char_in_Md 0]

I'm a Carefirst BCBS of MD member and I called to get the information about requirements for the surgery and they mentioned everything you posted except for the information about the option to do 2 managed diets for 3mths instead of waiting the full 6mths with one.

I have an appt with a nutritionist on June 9th, 2008 and want to get my ticker started. If I can get the surgery sooner than December, I'm all for it. I'll have to make sure that will work and move forward with that plan.

Thanks for the info,

Nat

:scared2:

may I ask what type of diets they are talking about and how you found a nutrionist? thanks for any info and hi neighbor!

[Nat0526 0]

may I ask what type of diets they are talking about and how you found a nutrionist? thanks for any info and hi neighbor!

I'm sorry it's taken me so long to respond, I didn't realize that you'd responded to my comment CharMD. I was referred to a nutritionist through my surgeon's office, but you can also look for nutritionists that are listed through the BCBS network.

I have a PPO plan, so I didn't need a referral to go to my nutritionist, but if you don't have a PPO plan, make sure to get a referral from your PCP so that it will be considered for your surgery. I've completed the 3mths with my nutritionist and I already had 3mths with a doctor monitored diet, so according to what I've read, I've met all the qualifications necessary. My BMI is over 40 and I got my pych eval already. Still trying to get in contact with the right staff member to ensure that my paperwork is submitted to Carefirst so I can get this ball rolling!!! I'm cautiously optimistic and very excited at the same time!! :smile:

Nat

[msavoy4901 0]

I have CareFirst and they will not pre-certify it they say as long as I meet the requirements, they will approve it when the claim is submitted. DOes that sound right to anyone else?