Bariatric Surgery Criteria for Coverage
To apply for coverage, you must fulfill the following criteria:
1. You must be ages 18 to 64. Under age 18 is not eligible for this surgery; over age 65 should contact Medicare.
2 . You must have a BMI of:
a. 40 or over, or
b. 35 to 39 with at least one of the following obesity-related comorbidity:
- Coronary heart disease
- Sleep apnea, or
c. 30 to 35 with Type II Diabetes Mellitus.
All medical policy criteria must be met in order to obtain a preauthorization, including:
1. Participation in a structured, medically supervised weight-loss program* for at least six months. Clinical records must be provided that demonstrate that the program:
- Includes at least three visits for medical supervision occurring no more than four months apart (for example, at the start, midpoint, and end of a six-month program). These visits must include assessment and counseling concerning weight, diet, exercise, and behavior modification.
- Is supervised by an MD, DO, ARNP, or PA; or by a registered dietician under the supervision of an MD, DO, ARNP, or PA.
*A comprehensive commercial program (such as Weight Watchers) may be acceptable, but must still fulfill the criteria for medical supervision listed above.
ALERT! The plans do not cover costs associated with weight-loss programs. Members are responsible for the full program cost. This amount does not apply to your deductible or out-of-pocket maximum.
2. Psychological evaluation by a licensed psychologist, psychiatrist, clinical social worker, or professional counselor; a licensed Masters level counselor; or a nurse practitioner in a behavioral health practice. This evaluation must document the absence of significant psychological issues that could limit the member’s ability to comply with medical/surgical recommendations.
3. Clinical documentation that the member is willing and able to comply with preoperative and postoperative treatment plans.
Women of Childbearing Age
Women of childbearing age who want to be considered for bariatric surgery must commit to not becoming pregnant after surgery until their provider determines it's safe to do so. They need to work with their provider to establish a treatment plan, including identification of the method of contraception they will use during this period. Their providers must educate them regarding the risk of maternal malnutrition, which may impair normal fetal development.
See "Bariatric Surgery and Medicare Coverage" if you are age 64 and will soon be eligible for Medicare.