Bariatric Surgery Criteria for Coverage
To apply for coverage, you must fulfill the following criteria:
1. Ages 21 to 64 or ages 18 to 20. Under age 18 is not eligible for this surgery; over age 65 should contact Medicare.
2 . a. BMI of 40 or over; or
b. BMI of 35 to 39 with a diagnosis of:
- Diabetes; or
- At least two of the following comorbid conditions (that have not responded to medical management and are expected to improve following bariatric surgery):
- Coronary heart disease
- Sleep apnea
Once your application is accepted, you will be assigned a Regence case manager. Before referral to a bariatric Center of Excellence, the following criteria must be met:
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 evaluation of weight loss, 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 listed above. Your Regence Case Manager will work with you to ensure the program you choose fulfills the necessary criteria. You are responsible for all costs associated with such a weight-loss program.
2. Psychological evaluation by a licensed psychiatrist, psychologist, or licensed clinical social worker. 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.
4. The member agrees that only the following procedures are covered:
a. Ages 21-64: Only Roux-en-Y, sleeve gastrectomy, or laparoscopic gastric banding surgery is covered.
b. Ages 18-20: Only laparoscopic gastric banding surgery is covered.
Women of Childbearing Age
Women of childbearing age who want to be considered for bariatric surgery must show they have received reproductive and contraceptive counseling. They must commit to not becoming pregnant after surgery until their provider determines it's safe to do so. They must inform their provider and case manager what secure birth control method they will use during this period. They must show that they have been informed about 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.