- General Health
- Aetna
- Blue Cross-Blue Shield
- TriCare/Champus
- Beechstreet
- United Healthcare
related articles and information:
Proposed insurance changes
- Medically supervised weight loss effort documentation: This means that your doctor's progress notes should document that you have been following a specified diet, with or without medication, for a period of at least 6 consecutive months, preferably but not necessarily with monthly weigh-ins and documentation of following the specified plan. It would also be helpful to include documentation of some form of exercise or document to why exercise can not be performed.
- Documentation of weight over the past 5 years: This means that you need formal documentation of your weight for each year of the last 5 years (for example, a physician's progress note from each year).
- Recent TSH showing that your thyroid is not contributing to your being overweight or documentation showing that your thyroid disease is under control with medication.
- A psychological evaluation addressing weight loss surgery. This needs to be performed by a psychiatrist or psychologist. (Most providers know what is required for documentation).
- A recommendation letter from your primary care provider
***Your particular plan may also require other documentation such as a nutritional evaluation, etc.
1. Presence of morbid obesity that has persisted for at least 5 years, defined as either:
- Body mass index (BMI) exceeding 40; or
- BMI greater that 35 in conjunction with ANY of the following sever co-morbidities:
- Coronary heart disease; or
- Type 2 diabetes mellitus; or
- Clinically significant obstructive sleep apnea; or
- Hypertension (BP>140 systolic and/or 90 diastolic); AND
2. Patient is at least 18 years old; AND 3. Patient has participated in a physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record.
This physician-supervised nutrition and exercise program must meet ALL of the following:
- Participation in nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; AND
- Nutrition and exercise program must be 6 months or longer in duration; AND
- Nutrition and exercise program must occur within the two years prior to surgery; AND
- Participation in physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who does not perform Bariatric surgery.
Note: A physician's summary letter is not sufficient documentation.
Insurance Requirements for Blue Cross Blue Shield Plans
***(first make sure your plan does not exclude obesity surgery)
- Medically supervised weight loss effort documentation: This means that your doctor's progress notes should document that you have been following a specified diet, with or without medication, for a period of at least 6 consecutive months, preferably but not necessarily with monthly weigh-ins and documentation of following the specified plan. It would also be helpful to include documentation of some form of exercise or document to why exercise cannot be performed.
- Documentation of weight over the past 5 years: This means that you need formal documentation of your weight for each year of the last 5 years (for example, a physician's progress note from each year).
- Recent TSH showing that your thyroid is not contributing to your being overweight or documentation showing that your thyroid disease is under control with medication.
- A psychological evaluation addressing weight loss surgery. This needs to be performed by a psychiatrist or psychologist. (Most providers know what is required for documentation).
- A recommendation letter from your primary care provider.
If patient has BMI greater that 35 but less than 40, patient must have on of the following:
- Diabetes
- Hypertension
- GERD
- Sleep Apnea
- Osteoarthritis
- Coronary Artery Disease
- High Cholesterol
If patient has a BMI over 40, patient does not need to have one of the conditions mentioned in the above list.
Patient over 65 years of age is not eligible for this procedure.
Patient needs to have an obesity history over past 5 years.
Documentation of at least 6 months of continued obesity even with a physician's help.
Patient must have no history of alcohol or drug abuse.
Patient must understand all risks associated with this procedure.
Patient will need to have dietary consult from their local dietician; this is an absolute requirement.
Patient must have a psychological consultation.
Patient must have peptic ulcer ruled out by one of the following methods:
- EGD
- Upper GI
- H. pyloric
- Patient must have a thyroid test (TSH).
- Medically supervised weight loss effort documentation: This means that your doctor's progress notes should document that you have been following a specified diet, with or without medication, for a period of at least 6 consecutive months, preferably but not necessarily with monthly weigh-ins and documentation of following the specified plan. It would also be helpful to include documentation of some form of exercise or document to why exercise cannot be performed.
- Documentation of weight over the past 5 years: This means that you need formal documentation of your weight for each year of the last 5 years (for example, a physician's progress note from each year).
- Recent TSH showing that your thyroid is not contributing to your being overweight or documentation showing that your thyroid disease is under control with medication.
- A psychological evaluation addressing weight loss surgery. This needs to be performed by a psychiatrist or psychologist. (Most providers know what is required for documentation).
- A recommendation letter from your primary care provider.
We are already seeing this pattern emerge. Presently, they do not want to cover the adjustable lap-band due to ignorance.
We feel it is important to notify you about these possible changes as it can affect your life! You - the potential patient - need to join together as a collective voice and question your insurance companies, write letters to the CEOs of your insurance companies, and write letters to your Insurance Commissioner.
If no one speaks up, no one can be heard.
But, the chances of our collectives voice being heard is magnified.
At Blue Cross and Blue Shield of Florida, Inc., and Heath Options, Inc., we strive to keep you informed of changes to our programs, services, health care coverage and benefits.
The enclosed endorsement reflects a change in coverage for weight loss surgeries and services. As of your next anniversary date, the enclosed 'Exclusion Of Coverage For Morbid Obesity Surgical Procedures'? endorsement will be effective. However, this endorsement will not be implemented until January 1, 2005 . We will be mailing the enclosed endorsement and letter to your employees in the next several days.
If you have any questions regarding this information, please feel free to contact your Blue Cross and Blue Shield of Florida sale representative or agent.
This endorsement is to be attached to and made a part of the current Health Options, Inc. (herein 'HOI') Certificate of Coverage and any endorsements attached thereto. The Certificate of Coverage is amended as described below.
The prior obesity treatment exclusion under the Exclusions and Limitations section of the Certificate of Coverage is deleted in its entirety and replaced with the following:
Weight Control Services including any service to lose, gain or maintain weight regardless of the reason for the service or whether the service is part of a treatment plan for a Condition. This exclusion includes, but is not limited to weight control/loss programs; appetite suppressants and other medications; dietary regimens; food or food supplements; exercise programs; exercise or other equipment; gastric or stomach bypass or stapling, intestinal bypass, gastric balloons, jaw wiring, jejunal bypass, gastric shunts, and procedures designed to restrict the Covered Person's ability to assimilate food.
All other provisions of the Certificate of Coverage shall remain unchanged.
This endorsement shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions, limitations, or conditions contained in the Certificate of Coverage, other than as specifically stated in this endorsement. In the event of any inconsistencies between the provisions contained I this endorsement shall control to the extent necessary to effectuate the intent of Health Options, Inc. as expressed herein.
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