Bad News on Appeal. Now What?

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 are any exclusions or other benefit limitations applicable to this service or supply.

The following criteria and guidelines have been developed to judge eligibility for coverage of bariatric surgery for the treatment of morbid obesity.

To be considered eligible for benefit coverage of bariatric surgery for treatment of morbid obesity, the following three criteria must be met:

A. A diagnosis of Morbid Obesity, defined as:

• Body Mass Index (BMI) of greater than or equal to 40 kg/meter squared; OR
• BMI greater than or equal to 35kg/meters squared with at least two (2) 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. Diabetes Mellitus,
4. Coronary heart disease, and/or
5. Sleep apnea.

AND

B. At least a five-year history of Morbid Obesity supported by medical record documentation.

AND

C. It is expected that appropriate non-surgical treatment should have been attempted prior to surgical treatment of obesity.

Non-surgical treatment of morbid obesity appropriateness criteria:

• Medical record documentation of active participation in a clinically-supervised, non-surgical program of weight reduction for at least 6 months, occurring within the twenty-four (24) months prior to the proposed surgery and preferably unaffiliated with the bariatric surgery program.
  NOTE: The initial BMI at the beginning of a weight reduction program will be the “qualifying" BMI used to meet the BMI criteria for the definition of morbid obesity used in this policy.
• A program will be considered appropriate if it includes the following components:

1. Nutritional therapy, which may include medical nutrition therapy such as a very low calorie diet such as MediFast or OptiFast OR a recognized commercial diet-based weight loss program such as Weigh****chers, Jenny Craig, etc.
2. Behavior modification or behavioral health interventions.
3. Counseling and instruction on exercise and increased physical activity.
4. Pharmacologic therapy (as appropriate).
5. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health.

Surgical Program for the treatment of morbid obesity documentation requirements:

• Documentation that growth is completed. Generally, growth is considered completed by 18 years of age or with documentation of completed bone growth.
• Evaluation by a licensed professional counselor, psychologist or psychiatrist, should be completed within the 12 months preceding the request for surgery. This evaluation should 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.
  2. Any psychological co-morbidities that are contributing to weight mismanagement or a diagnosed eating disorder.
  3. Patient’s willingness to comply with preoperative and postoperative treatment plans.

Significant relative contraindications for surgical treatment of obesity include:

• Mental handicaps that render a patient unable to understand the rules of eating and exercise and therefore make them unable to participate effectively in the post-operative treatment program. (An example is a patient with malignant hyperphagia (Prader-Willi syndrome), which combines mental retardation with an uncontrollable desire for food.)
• Portal hypertension, which is an excessive hazard when laparoscopic gastric surgery is performed.
• Age greater than 65 because for these patients the weight loss is less effective, the duration of benefits is shorter and the risks of the procedures are greater.