FEP BLUE TX states do not do predetermination of payment, anyone else have this

Title:

Surgery for Morbid Obesity

Number:

SUR716.003

Effective Date:

07-01-2006

Legislation:

ILLINOIS:  None

NEW MEXICO:  None

OKLAHOMA:

TEXAS:  None

FEDERAL (applies to all Plans):  None

Contract:

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan or contract to determine if there is any exclusion or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage:

Coverage for Bariatric surgery may be considered eligible for coverage in the treatment of morbid obesity when ALL the following criteria are met:

• Body Mass Index (BMI) of greater than or equal to 40 kg/meter squared OR a BMI greater than or equal to 35kg/meters squared with at least two of the following co-morbid conditions which have not responded to maximum medical management and which are generally expected to be reversed or improved by bariatric treatment:
  1. Hypertension
  2. Dyslipidemia
  3. Type 2 diabetes
  4. Coronary heart disease, and/or
  5. Sleep apnea
• A documented five-year history of morbid obesity (BMI greater than or equal to 40 kg/m squared). When medical records are requested, a letter of support and/or explanation is helpful but alone will not be considered sufficient documentation to make a medical necessity determination. Individual consideration may be given to patients who do not meet this criterion but are suffering from one or more of the co- morbid conditions noted above and these conditions are not responding to medical treatment.
• A documented failure of twelve (12) continuous months of compliance with medically supervised non-surgical methods of weight reduction.  Medical supervision must occur under an MD, DO, or an Advanced Practice Nurse or PA working under physician supervision (as required by licensure) within the previous 24 month period prior to the request.  A medically supervised weight management program is expected to consist of:
  1. Nutritional therapy or medical nutrition therapy including a very low calorie diet (e.g., MediFast or OptiFast) unless contraindicated.,
  2. Behavior modification or behavioral health interventions,
  3. Supervised increase in activity,
  4. Pharmacologic therapy (unless contraindicated),
  5. Maintenance support to continue to encourage nutrition choices to reduce health risk factors and maintain a healthy lifestyle.
• Evaluation by an independent, appropriately licensed professional counselor, psychologist or psychiatrist who is unaffiliated with the surgical program.  This evaluation must document:
  1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations; and
  2. Evaluation of psychological comorbidities that contribute to weight mismanagement; and/or eating disorder.
• Documentation of willingness to comply with preoperative and postoperative treatment plans; and
• Growth has been completed (18 years of age or documentation of completion of bone growth).