Surgical Treatment of Morbid Obesity

The medical need for this procedure must be established documenting that the enrollee has significant symptoms or functional impairments that cannot be adequately managed with more conservative, less invasive measures.  The following criteria are used when considering requests for surgical treatment of morbid obesity:

1. 1. Review of the health plan document to determine whether the procedure is a covered benefit.
   2. A statement from the patient’s primary care physician recommending the weight reduction surgery and that there are no contraindications to the proposed procedure, such as liver disease or psychosis.
   3. Documentation from the patient’s primary care physician of at least 3 months of an adequate trial of weight reduction techniques within the previous 2 years.  This is reviewed to establish that adequate conventional weight loss trials have been attempted and that the patient will able to comply with post-operative regimens.  This may or may not include use of prescription drugs for weight loss.  In the monthly documentation there must be details of the treatment plan, regular recording of patient’s weight, evidence of regular supervision/counseling by the primary care physician, including a dietary evaluation and evidence of patient compliance with the treatment plan. This criteria is waived if BMI is > than 40.
   4. Body Mass Index criteria: Metabolic & Bariatric Surgery would be considered for individuals with:
      • Body Mass Index (BMI) is >35 regardless of presence or absence, or severity of co-morbidities
      • Body Mass Index (BMI) between 30-35 and patient has been diagnosed with a significant life threatening co-morbidity by the primary care physician.  Examples of such co-morbidities include Congestive heart failure, Cardiomyopathy, Type 2 diabetes, Obstructive sleep apnea (OSA), Hypertension, Hyperlipidemia, Obesity-hypoventilation syndrome (OHS), Pickwickian syndrome,  fatty liver disease, Nonalcoholic steatohepatitis, Pseudotumor cerebri, Gastroesophageal reflux disease, Asthma, Venous stasis disease, Severe urinary incontinence, and Debilitating arthritis.
      • Asian patients BMI threshold is > 27.5 to account for genotypic differences resulting in higher comorbidities at lower BMIs.
      • Adolescent patients with a BMI >120% of the 95^th percentile and a major co-morbidity or a BMI > 140% of the 95^th percentile.
   5. In order to rule out the possibility of other treatable causes of the obesity, the enrollee’s primary care physician has determined that organic illness is not causing obesity, as the presence of such diseases may influence of the long-term success of the obesity surgery.  Examples of such diseases may include hypothyroidism, Cushing’s disease, hypothalamic lesions, or other endocrine abnormalities. 
   6. The patient is psychologically stable and able to understand and cope with the potential body image and lifestyle changes which may occur as a result of the proposed surgery, as documented by a written evaluation from a licensed behavioral health provider. 

    

    

    

   ConnectCare considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary and who meet the following criteria:

   • Conversion to a sleeve gastrectomy, RYGB, or BPD/DS is considered medically necessary for members who have not had adequate success 2 years after the original weight loss surgery, defined as weight loss that is still less than 50% of the pre-operative excess body weight and weight remains at least 30% over the patient’s ideal body weight, per BMI; or
   • Revision of a primary bariatric surgery procedure that has failed and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
   • Replacement of an adjustable band is considered medically necessary if there are complications that cannot be corrected with band manipulation or adjustments; or
   • Conversion from an adjustable band to a sleeve gastrectomy, GYGB or BPD/DS is considered medically necessary for members who have been compliant with a prescribed nutrition and exercise program following the band procedure, and there are complications that cannot be corrected with band manipulation, adjustments, or replacement; or
   • Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass for the treatment of gastro-esophageal reflux disease when anti-reflux medical therapy has been tried and failed.

        

   Approved:  2/01

   Reviewed:  2/08, 1/09, 2/11, 1/13, 3/14, 2/15, 1/16, 9/16, 1/17, 1/18, 1/19, 5/21, 10/23, 9/24

   Revised:   10/02, 4/03, 8/03, 3/04, 6/04, 10/05, 3/06, 10/06, 2/07, 3/10, 1/12, 3/14, 9/16, 1/18, 2/20, 6/20, 4/24