Insurance coverage eligibilty from:
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.
A physician's summary letter is not sufficient documentation.
www.aetna.com
www.cigna.com
Effective January 1 2005, weight loss surgery is not covered for most contracts. Please refer to the individual member's contract benefit language.
Certain surgical procedures performed for the treatment of clinically severe obesity may be considered medically necessary when ALL of the following conditions are met:
The member:
- meets the above definition of clinically severe obesity,
- has been severely obese for at least five (5) years,
- has attempted a physician supervised (by the primary care physician) non-surgical management weight loss program (e.g., diet, exercise, drugs) for six (6) consecutive months
- has received psychological or psychiatric evaluation with counseling as needed, prior to surgical intervention;
- Does not have a medically treatable cause for the obesity, (e.g., thyroid or other endocrine disorder).
NOTE: The primary care physician must provide a letter with facts supporting medical necessity, for review by the Medical Director.
www.bcbsfl.com
www.avmed.com
TRICARE coverage is limited to three types of surgical treatment for obesity: gastric bypass, gastric stapling, and gastroplasty, including "vertical banded" gastroplasty, when one of the following conditions is met:
A patient is 100 pounds or more over the ideal weight for height and body structures, and has one of these associated medical conditions:
- Diabetes mellitus,
- Hypertension,
- Cholecystitis,
- Narcolepsy,
- Pickwickian Syndrome (and other severe respiratory diseases),
- Hypothalamic disorders,
- and severe arthritis of the weight bearing joints.
A patient is 200 percent or more of the ideal weight for height and body structure.
An associated medical condition is not required for this category.
www.mytricare.com
- A letter of medical necessity for bariatric surgery, including duration of morbid obesity and determination that there is no treatable cause for the obesity.
- Medical records documenting diagnoses and appropriate treatment of co-morbid conditions.
- Documentation that patient has failed to lose weight or has regained weight despite participation in a three (3) month physician-supervised multi-disciplinary program within the past six (6) months that included:
- Dietary Therapy (low 800-1200 calorie diet)
- Physical activity (moderate levels of activity for 30-45 minutes 3-5 days per Week should be encouraged)
- Behavior therapy and support.
- Current height and weight, including BMI
- A summary of a psychological evaluation from a licensed behavior health professional related to the diagnoses attesting to the appropriateness of the candidate for the procedure and members ability/willingness to comply with the postoperative regimen and all psychological issues have been identified and addressed.
- Evaluation and records form a nutritional counselor or dietician regarding the member's ability to comply with postoperative regimen.
- A summary of a cardiac evaluation and clearance form a cardiologist if there is a history of Phen-Fen or Redux use.
- A summary of a pulmonary evaluation and clearance for restrictive lung disease from pulmonologist.
- Plans for participation in a postoperative multidisciplinary program that includes guidance on diet, physical activity and behavior and social support.
Documentation that the patient has been severely obese for at least five (5) years (must be documented in actual progress notes from your physician).
www.unitedhealthcareonline.com
Please note that Effective 10\01\2006, Dr. Jawad has Opted-Out of Medicare and is No Longer a Provider for Medicare.
Dr. Shebani is a Medicare provider and is presently accepting Medicare patients for Gastric Bypass surgery. Medicare patients whom are considering Bariatric Surgery should call the office to arrange for a consult with Dr. Shebani to discuss their surgical options.
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