Insurance Requirements
It is the patient's responsibility
to call their insurance carriers member service department
to verify the benefit and requirements for obesity surgery.
All insurance carriers provide the benefit to cover obesity
surgery, but some employers elect not to provide the
benefit.
All insurance carriers require that patients meet the
standard requirement, as listed below:
- Surgical treatment of morbid obesity
— a condition in which an individual's Body
Mass Index (BMI) is greater than 35 with documented
comorbidities or a BMI of 40 or greater without documented
co morbidities
- Eligible patients must be age 18 or over
CAREFIRST BCBS (excluding fep
groups 104 and 105)
- Attempted a structured weight loss
program for (6) consecutive months or (2) structured
diet programs for (3) consecutive months within the last
(2) years; can include: Weight Watchers, Jenny Craig,
of LA Weight Loss Centers (receipts are required as proof
of participation)
- Psychological evaluation
- Nutritionist
- Letter from PCP
- Maryland based small groups do
not have the covered benefit
for obesity surgery.
Patients must have a referral if required by plan.
- National Accounts — need to check
each patient's account; may have the clause "if
deemed medically necessary"
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AETNA
- Weight documented once a year for (2) years
- Psychological evaluation
6-Month Program
- Proof of participation in a medically
physician supervised nutrition and exercise program
within the last (2 years for a consecutive (6) months (Note:
A physician's summary letter is not sufficient documentation).
- Nutrition evaluation
3-Month Program
- Multidisciplinary surgical preparatory
regimen: member must participate in an organized
surgical preparatory regimen of at least three consecutive
months (each specialist) duration, proximate to the
time of surgery, meeting all of the following criteria;
(1) consultation with a dietician or nutritionist,
(2) a reduced-calorie diet program supervised by
a dietician or nutritionist, (3) an exercise regimen
(unless contraindicated) to improve pulmonary reserve
prior to surgery, supervised by exercise therapist
or other qualified professional, (4) behavior modification
program supervised by a qualified professional, (5)
documentation in the medical record of participation,
should include medical records of the physician's
initial assessment, and an assessment of the member's
progress at the completion of the multidisciplinary
surgical preparatory regimen
CIGNA
- Clinical documentation of a physician
supervised weight loss program with a duration of six
(6) consecutive months within the last 2 years (5 yrs.
if lifelong obesity)
- Letter for your primary care physician that includes
your current medications, any known history of alcohol
abuse, a recommendation for gastric bypass surgery
- Psychological evaluation
- Nutritional evaluation
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Mamsi/Alliance PPO/M.D.I.P.A./Optimum
Choice (United Healthcare)
- Letter of Medical Necessity from PCP,
to include documentation of smoking status, the name
of smoking cessation program and the progress if currently
smoking: and additional office notes documenting the
use of medication for weight loss
- Participation in a structured diet program weight loss
program during the last (2) years for (6) consecutive
months of (2) programs for (3) consecutive months
- Psychological evaluation
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Mail Handlers
- Participation in a physician supervised
weight loss program during the last (6) months for a
consecutive (3) months
- PCP letter
- Cardiologist
- Pulmonologist
- Gastroenterologist
- Psychological evaluation
- Nutritional evaluation
- TSH
- Post surgical regimen
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DC Chartered Health/Healthright Medicaid
- The plan will evaluate on a case by
case basis, as there are limited benefits for obesity
surgery
- 6 month physician supervised weight
management program
- TSH
- All specialist testing
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DC Medicaid
- (1) year physician supervised weight
management program
- Photos of body only
- All specialists testing
Amerigroup, MD (Case-by-Case basis)
- Letter documenting obesity for five
years
- Psychological Evaluation
- EKG
- EGD
- Drug and alcohol screening
- Letter from PCP
- Supervised diet monitoring for 6 consecutive months w/i
(1) yr.
(Nutritionist, Weight Watchers, or Jenny Craig is acceptable)
- Additional information maybe requested upon review
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MD Medicaid
- All testing is reviewed, then
it is determined whether weight management will be
required
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