so pissed about great west healthcare!

GREAT WEST HEALTHCARE

Required Documentation:

• Presence of morbid obesity with a Body mass index (BMI)* of 40 or greater than 35 with a significant co-morbid condition such as:

A. Life threatening cardiopulmonary disease; or

B. Disabling degenerative joint disease of the lower extremities; or

C. Type 2 diabetes mellitus; or

D. Obesity related pulmonary hypertension

E. Clinically significant asthma; or

F. Obesity related cardiomyopathy; or

G. Moderate to severe gastric esophageal reflux disease; or

H. Uncontrolled hypertension.

• Minimum age of 18.
• Weight management history whi*****ludes all of the following:
  • A. Obesity duration greater than five years.
  • B. Participation in a weight loss program for six months (within the last two years) with chart notes that include documentation of all of the following:
    • a. Dietary program for weight loss which consists of a very low calorie diet program (i.e. Optifast), Nutri-Systems, Jenny Craig or Weigh****chers whi*****ludes monthly weigh-ins and nutritional analysis.
    • b. Monthly clinical encounters with a healthcare professional who does not perform weight loss surgery.
    • c. Increased activity/exercise regimen unless contraindicated.
    • d. Behavior modification program supervised by a qualified professional to reinforce dietary therapy and increased physical activity.
    • e. Weight loss management history includes pharmacotherapy with physician prescribed weight loss drugs or documentation of why pharmacotherapy was not tried.
• Multidisciplinary pre-operative evaluation that includes all the following:

  A. Nutritional evaluation by a licensed nutritionist, dietitian or physician.

  B. Medical evaluation that addresses endocrine disorder or other cause of excessive weight gain that might

  be reversible without surgery

  C. Psychological evaluation by a licensed mental healthcare professional that addresses the following:

  • a. Absence of problems related to alcohol or substance abuse for at least one year.
  • b. Absence of major psychotic or disabling mental health diagnosis including mania,
  • schizophrenia, et. al.
  • c. Absence of compulsive or obsessive-compulsive disorder.
  • d. Eating disorders (i.e. bulimia)
  • e. Likelihood of willingness to comply with post-op requirements.
• Commitment to planned post-op multidisciplinary approach that includes on-going regular meetings, at least monthly for first six months post-op, with psychiatric or psychological support/consultation and dietician or nutritionist support/consultation and exercise.

Great-West will deny our request for obesity surgery if this documentation is not provided, therefore we will not contact your insurance company until we receive this documentation