Blue Cross Blue Shield of Michigan

I received a letter in the mail yesterday from BCBSM with the information that was provided to me over the phone earlier this week. I know that many BCBS plans are different, but I thought I'd share what my letter stated as far as coverage is concerned for bariatric surgery.

P.S. - I have Blue Cross Blue Shield of Michigan - Community PPO

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Gastric Bypass / Adjustable Gastric Banding Surgery

Fact Sheet

Approved bariatric surgical procedures, including sleeve gastrectomy, are considered established for the treatment of morbid obesity if all of the following criteria are met:

• The patient has a body mass index greater than 40, or a BMI of greater than 35 with comorbid (accompanying) conditions such as degenerative joint disease, hypertension, hyperlipidemia, coronary artery disease, presence of other atherosclerotic diseases, type 2 diabetes mellitus, sleep apnea or congestive heart failure.
   
• Risks and benefits of the planned surgery, including those related to the patient's age, should be documented in the clinical record. BCBSM has no age requirements for bariatric surgery for adults.
   
• The patient must be clinically evaluated by an M.D. or D.O. The physician must document, in the medical record, the failure of non-surgical efforts to lose weight. The document must include that the patient participated in a structured, professionally supervised (physician or non-physician) weight-loss program for a minimum of six consecutive months within the last four years prior to the recommendation for bariatric surgery. (The requirement to participate in a weight-loss program is waived for super morbidly obese individuals who have a BMI greater than 50.) Documentation also should include periodic weight, dietary therapy and physical exercise, as well as behavioral therapy, counseling and pharmacotherapy, as indicated.
   
• The surgeon should document that the patient understands the benefits and risks of the available surgical and non-surgical management strategies. This documentation also must include an informed decision to proceed with bariatric surgery with an understanding of the surgical risk and the commitment to medical management thereafter.
   
• A contracted mental health professional must perform a psychological evaluation prior to the surgery to establish the patient's emotional stability, ability to comprehend surgery risks and to give informed consent, and ability to cope with expected postsurgical lifestyle changes and limitations. This consultation may include one unit of psychological testing for personality assessment (for example, the MMPI-2 or the adolescent version, the MMPI-A).
   
• The physician should arrange follow-up with the patient to monitor for any long-term complications occurring as a results of gastric surgery.

In cases where a revision of the original procedure is planned, documentation of all of the following is required:

• Date and type of previous procedure
   
• Factors that precipitated failure
   
• Complications from the previous procedure that affect the patient's inability to maintain the weight loss. If the indication for the revision is a failure of the patient to lose a desired amount of weight, then the patient must meet all of the initial preoperative criteria.