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HSA Plan

Network

20% coinsurance after deductible

Non-Network

Not covered

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

Not covered

PPO 1250 Plan

Network

20% coinsurance after deductible

Non-Network

Not covered

The surgery must be performed at a facility accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) for the billed procedure.

Preauthorization by medical plan required.

Covered Procedures

Coverage limited to the following open or laparoscopic bariatric surgery procedures:

  • Roux-en-Y gastric bypass;
  • Sleeve gastrectomy;
  • Adjustable silicone gastric banding (such as LAP-BANDĀ® or REALIZEā„¢). Adjustments of a silicone gastric banding are covered to control the rate of weight loss and/or treat symptoms secondary to gastric restrictions after a covered adjustable silicone gastric banding procedure;
  • Biliopancreatic diversion with duodenal switch (BPD/DS) for individuals with a body mass index (BMI) greater than 50;
  • Surgical reversal of bariatric surgery is covered when complications of the original surgery (such as stricture, obstruction, pouch dilatation, erosion, or band slippage) cause abdominal pain, inability to eat or drink, or cause vomiting of prescribed meals;
  • Revision of a previous bariatric surgical procedure or conversion to another medically necessary procedure due to inadequate weight loss is covered when all of the following are met. Inadequate weight loss due to individual non-compliance with post-operative nutrition and exercise recommendations is not a medically necessary indication for revision or conversion surgery and is not covered:
    • There is evidence of full compliance with the previously prescribed post-operative dietary and exercise program; or
    • There is documented clinical testing demonstrating a technical failure of the original bariatric surgical procedure which caused the individual to fail at losing at least 50 percent of excess body weight or fail to achieve body weight to within 30 percent of ideal body weight at least two years following the original surgery.

Criteria to Meet

Covered only when the following criteria have been met:

  • The member is 18 or older or has reached full skeletal growth, and has evidence of 1 of the following:
    • BMI greater than 40; or
    • BMI between 35 and 39.9 and 1 or more of the following:
      • Type 2 diabetes;
      • Cardiovascular disease such as stroke, myocardial infarction, stable or unstable angina pectoris, hypertension or coronary artery bypass; or
      • Life-threatening cardiopulmonary problems such as severe sleep apnea, Pickwickian syndrome or obesity-related cardiomyopathy;
  • Demonstration that dietary attempts at weight control have been ineffective through completion of a structured diet program. Commercial weight loss programs are acceptable if completed under the direction of a provider or registered dietitian and documentation of participation is available for review. One structured diet program for 6 consecutive months or 2 structured diet programs for 3 consecutive months each within a 2-year period prior to the request for the surgical treatment of morbid obesity are sufficient. Provider-supervised programs consisting exclusively of pharmacological management are not sufficient
  • A thorough multidisciplinary evaluation within the previous 12 months, which includes all of the following:
    • An evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure and all of the associated current procedural terminology codes;
    • A separate medical evaluation from a provider other than the surgeon recommending surgery that includes a medical clearance for bariatric surgery;
    • Completion of a psychological examination from a mental health provider evaluating the member's readiness and fitness for surgery and the necessary post-operative lifestyle changes. After the evaluation, the mental health care provider must provide clearance for bariatric surgery;
    • A nutritional evaluation by a provider or registered dietitian.

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