Bariatric Surgery Criteria for Coverage
To be considered for coverage of bariatric surgery, members must meet the following criteria. They also must comply with all presurgical requirements set by UMP through case management, including achieving a specific weight-loss goal through participation in a structured weight-loss program as required by their assigned bariatric surgery provider. The decision to approve bariatric surgery can be delayed, or even denied, if previously approved candidates do not comply with these requirements.
All criteria listed below must be met:
- Be between the ages of 21 to 64 for coverage of Roux-en-Y surgery and between the ages of 18 to 64 for laparoscopic adjustable gastric banding surgery. Members covered by Medicare should check with Medicare for coverage.
- Have not had any type of bariatric surgery within the last 10 years.
- Be morbidly obese with a body mass index (BMI) of 40 or greater.
- Be diagnosed with one of the following diseases: diabetes, hypertension, high cholesterol (hyperlipidemia or dyslipidemia), sleep apnea, Pickwickian syndrome or Pseudotumor Cerebri.
- Have evidence of previously failed attempts at losing weight.
- Have a psychological evaluation that indicates a strong readiness for change and absence of mental disorders that could impact the success of the surgery.
- Work with a case manager during the entire process and comply with all requirements before surgery and for two years after surgery.
- Participate in a structured weight-loss program as required by UMP bariatric surgery criteria and your bariatric provider.
- Not have medical conditions that would increase the risk of surgical mortality (death) or morbidity (complications) including but not limited to the following conditions: unstable coronary artery disease, severe pulmonary disease, portal hypertension with gastric or intestinal varices, or other conditions thought to seriously compromise anesthesia or wound healing.
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.