Devastated

Patient Selection Criteria for Adults

1. The patient is morbidly obese;
   
   Morbid obesity is defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% over ideal weight or a BMI of at least 40 or a BMI of 35 with comorbidities (e.g., hypertension, cardiovascular heart disease, dyslipidemia, diabetes mellitus type II, sleep apnea).
   
    
2. The patient is at least 18 years old; and
   
    
3. The patient has received non-surgical treatment (e.g., dietitian/nutritionist consultation, low calorie diet, exercise program, and behavior modification) and attempts at weight loss have failed.
   
    
4. The patient must participate in and meet the criteria of a structured nutrition and exercise program.  This includes dietitian/nutritionist consultation, low calorie diet, increased physical activity, behavioral modification, and/or pharmacologic therapy, documented in the medical record.  This structured nutrition and exercise program must meet all of the following criteria:
   
    
   • The nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
   • The nutrition and exercise program(s) must total 6 visits or more during a period of six consecutive months; and
   • The nutritional and exercise program must occur within two years prior to the surgery; and
   • The patient's participation in a structured nutrition and exercise program must be documented in the medical record by an attending physician who supervised the patient's progress.  A physician's summary letter is not sufficient documentation.  Documentation should include medical records of the physician's on-going assessments of the patient's progress throughout the course of the nutrition and exercise program.  For patients who participate in a structured nutrition and exercise program, medical records documenting the patient's participation and progress must be available for review.
     
      
5. The patient must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery.  The patient's medical record documentation should indicate that all psychosocial issues have been identified and addressed.
   
    
6. Patient selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach.  The member's understanding of the procedure, and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure.

If the patient does not meet all of the patient selection criteria for bariatric surgery, the procedure will be denied as not medically necessary.