Post by smokinstella on Jan 10, 2012 11:59:34 GMT -5
I found this, if you have wellcare as your managed health plan www.wellcare.com/WCAssets/corporate/assets/HS006_Bariatric_Surgery.pdf
Bariatric Surgery for the treatment of morbid obesity is considered medically necessary when the following criteria are met:
1. Presence of morbid obesity, defined as either:
a. Body mass index (BMI)* exceeding 40; OR,
b. BMI* greater than 35 in conjunction with ANY of the following severe co-morbities:
1) Coronary heart disease; OR,
2) Type 2 diabetes mellitus; OR,
3) Clinically significant obstructive sleep apnea ( i.e., member meets the criteria for treatment of obstructive sleep apnea; OR,
4) Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);
* NOTE: BMI is calculated by dividing the patient’s weight (in kilograms) by the height (in meters) squared: *BMI = weight (kg) / [height (m)] 2 (To convert pounds to kilograms, multiply pounds by 0.45. To convert inches to meters, multiply inches by 0.0254)
AND
2. Member has completed growth (18 years of age or documentation of completion of bone growth);
AND
3. The member must concurrently participate in an organized multidisciplinary surgical preparatory regimen coordinated by a qualified bariatric surgeon in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions.
AND
4. Member has participated in a physician-supervised nutrition and exercise program (including a low calorie diet, increased physical activity, and behavioral modification). This physician-supervised nutrition and exercise program must meet ALL of the following criteria:
a. Participation in nutrition and exercise program must be supervised and monitored by a physician; AND,
b. Nutrition and exercise program must be 6 months or longer in duration; AND,
c. Nutrition and exercise program must occur within the two years prior to surgery; AND,
d. Participation in physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who does not perform bariatric surgery. Note: A physician’s summary letter is not sufficient documentation.
Programs such as Weight Watchers®, Jenny Craig® and Optifast® are acceptable alternatives if done in conjunction with physician supervision and detailed documentation of participation is available for review. However, physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.
AND
5. Mental health evaluation by a psychiatrist or psychologist to determine any contraindications as listed below, mental competency and understanding of the nature, extent and possible complications of the surgery and ability to sustain dietary behavioral modifications needed to ensure a successful outcome of surgery. Contraindicated diagnoses are:
a. Active drug abuse
b. Active suicidal ideation
c. Borderline personality disorder
d. Schizophrenia
e. Psychotic disorder
f. Uncontrolled depression
g. Defined non-compliance with previous medical care
Procedures Covered
Only the following surgical procedures are covered:
a. Gastric segmentation along its vertical axis with a Roux-en-Y bypass with distal anastomosis placed in the jejunum (Open - CPT 43846 or 43847 and Laparoscopic -CPT 43644)
b. Laparoscopic adjustable silicone gastric banding (LASGB) (CPT 43770)
c. Biliopancreatic Diversion with Duodenal Switch (Open -CPT 43847)
d. Laparoscopic or open sleeve gastrectomy; laparoscopic longitudinal gastrectomy
Non-Covered Procedures
The following procedures are not covered due to being unsafe or not adequately studied:
a. Open adjustable gastric banding (CPT 43843)
b. Open and laparoscopic vertical banded gastroplasty (CPT 43842)
c. Gastric balloon (CPT 43843)
d. Intestinal bypass (CPT43659 )
Bariatric Surgery for the treatment of morbid obesity is considered medically necessary when the following criteria are met:
1. Presence of morbid obesity, defined as either:
a. Body mass index (BMI)* exceeding 40; OR,
b. BMI* greater than 35 in conjunction with ANY of the following severe co-morbities:
1) Coronary heart disease; OR,
2) Type 2 diabetes mellitus; OR,
3) Clinically significant obstructive sleep apnea ( i.e., member meets the criteria for treatment of obstructive sleep apnea; OR,
4) Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);
* NOTE: BMI is calculated by dividing the patient’s weight (in kilograms) by the height (in meters) squared: *BMI = weight (kg) / [height (m)] 2 (To convert pounds to kilograms, multiply pounds by 0.45. To convert inches to meters, multiply inches by 0.0254)
AND
2. Member has completed growth (18 years of age or documentation of completion of bone growth);
AND
3. The member must concurrently participate in an organized multidisciplinary surgical preparatory regimen coordinated by a qualified bariatric surgeon in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions.
AND
4. Member has participated in a physician-supervised nutrition and exercise program (including a low calorie diet, increased physical activity, and behavioral modification). This physician-supervised nutrition and exercise program must meet ALL of the following criteria:
a. Participation in nutrition and exercise program must be supervised and monitored by a physician; AND,
b. Nutrition and exercise program must be 6 months or longer in duration; AND,
c. Nutrition and exercise program must occur within the two years prior to surgery; AND,
d. Participation in physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who does not perform bariatric surgery. Note: A physician’s summary letter is not sufficient documentation.
Programs such as Weight Watchers®, Jenny Craig® and Optifast® are acceptable alternatives if done in conjunction with physician supervision and detailed documentation of participation is available for review. However, physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.
AND
5. Mental health evaluation by a psychiatrist or psychologist to determine any contraindications as listed below, mental competency and understanding of the nature, extent and possible complications of the surgery and ability to sustain dietary behavioral modifications needed to ensure a successful outcome of surgery. Contraindicated diagnoses are:
a. Active drug abuse
b. Active suicidal ideation
c. Borderline personality disorder
d. Schizophrenia
e. Psychotic disorder
f. Uncontrolled depression
g. Defined non-compliance with previous medical care
Procedures Covered
Only the following surgical procedures are covered:
a. Gastric segmentation along its vertical axis with a Roux-en-Y bypass with distal anastomosis placed in the jejunum (Open - CPT 43846 or 43847 and Laparoscopic -CPT 43644)
b. Laparoscopic adjustable silicone gastric banding (LASGB) (CPT 43770)
c. Biliopancreatic Diversion with Duodenal Switch (Open -CPT 43847)
d. Laparoscopic or open sleeve gastrectomy; laparoscopic longitudinal gastrectomy
Non-Covered Procedures
The following procedures are not covered due to being unsafe or not adequately studied:
a. Open adjustable gastric banding (CPT 43843)
b. Open and laparoscopic vertical banded gastroplasty (CPT 43842)
c. Gastric balloon (CPT 43843)
d. Intestinal bypass (CPT43659 )