*GP( @ r UQ T9 Medicaids Criteria for Weight Loss Surgery Coverage. Internal Medical Policy Committee 1-20-2022 Revision with coding updates; . hbbd```b`` "HE`Z09D|&&_IO`" H2nb3w Z'[A$)X}L?o F_ Goal Weight: 149 lbs. If a patient is less than 18 years of age, a letter . Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Bariatric Surgery Which Procedure Is Best? Northeast Georgia Medical Center (NGMC) offers a variety of surgical and nonsurgical weight-loss options and is an Anthem Blue Cross Blue Shield Blue Distinction Center for Bariatric Surgery. B#UVjHJ)Uc_;(T;ZAYQ}_B4UC3{mo Check here bluecross blueshield fed blue bariatric official portal step by step. In general, 20% to 30% above "ideal" bodyweight, according to standard life insurance tables, constitutes obesity. *GP( @ r UQ T9 GQ^3>EtB0Pq*%`4)}S[]6 Va.sMnLdEcobqV}un s^-(w=f(o`?~~qC 7KPDBBERo>(^Bg,{8uWU tASR/a^_NX,vfUrOG(!YW_^H *GP( @ r UQ T9 1J-z](5K+XkXU)zc+2gUnRsXuQ@t>icv- {7V}*ymha.JS10NL](wnj`"5c+8L5TwB0mgbP{C]Z#H4:s PCD4N0"Pz}KP7A@mDY*/yiI @Z22*;/-"i1-mhqe,@e*De)KW8vYiI @Z22*;/-"iq@M&, e * PY$(NY`!%'NZ2 AHTyiHV}%0D0r, e9(KDElW4m'NZ2 AHTyiHm>e ,@e(, 8e"Q4Z'NZ2 AHTyiHu}fOY? e,@e*bs HYA$RV A*6 bhu/D0Cxi9 H! 2022 Policy Documents. *GP( @ r UQ T9 Bariatric Surgery . % 500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM Long-Limb Gastric Bypass (le, >150 cm) (CPT code 43847 - Gastric restrictive procedure with Morbid What is a Weight Loss Seminar? 0 there are documented recurrent or chronic rashes, infections, cellulitis, or non-healing ulcers, that do . Attainment or near-attainment of physiologic/skeletal maturity at approximately, age 13 in girls and 15 for boys. endstream Individual outcomes may vary. *GP( @ r UQ T9 They are: This list is not comprehensive. The eligible bariatric surgical procedures listed above unless otherwise specified may be considered medically necessary for individuals under the age of 18 years when they meet Oklahoma Medicare, health insurance renewal for individuals & families, Making Your Health Insurance Work For You, Prescription Drug Changes and Pharmacy Information, Machine Readable Files for Transparency in Coverage. endstream endobj startxref Open Gastric Bypass Surgery This procedure is rare and only performed under particular medical circumstances. We recommend that you only use this publication in conjunction with the current year's health premium rate schedule and EOCs. <> Any bariatric surgeon that accepts Blue Cross Blue Shield of Michigan will know where the surgery has to take place. rvYWDgg!MxV Revisions are covered if there is documentation of a failure secondary to a surgical complication. If this is the case and you find a second surgery or procedure is needed, you might find that Blue Cross Blue Shield does provide coverage for a second surgery as long as you followed post-operative instructions and made lifestyle changes for success as well as turned to the bariatric surgeon and other sources for additional help. *GP( @ r UQ T9 *GP( @ r UQ T9 If you are considering covered cardiac procedures, cancer care, knee or hip replacement, or spine surgery . Centers for Bariatric Surgery. The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed; The individual must be able to show decisional capacity and maturity in the psychological evaluation and provide informed assent for surgical management; The individual must be capable and willing to adhere to nutritional guidelines postoperatively; The individual must have a supportive and committed family environment; Selection criteria is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. endstream endobj 749 0 obj <. This new site may be offered by a vendor or an independent third party. To view this file, you may need to install a PDF reader program. *GP( @ r UQ T9 Morbid obesity is further defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. *GP( @ r UQ T9 Consult and recommendation from a weight loss surgeon. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. endobj The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed; Psychological evaluation documentation must be within the last year; Individual selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. Original Effective Date: December 2015. *GP( @ r UQ T9 endobj and comply with all phases of pre- and post-operative care and is committed to long-term post-operative follow-up requirements; and . Bariatric Surgery Which Procedure Is Best? The answers to these questions will vary considerably based . *GP( @ r UQ T9 Blue Cross Blue Shield Association. *GP( @ r UQ T9 @h23Begj!b4ZJ2}Y*bPc6d 5d 05dD/Br,Fsr#0Yi^kRsTCx aEt! *GP( @ r UQ T9 If your policy covers gastric bypass then it should cover other bariatric surgery procedures as well. or 100% over ideal weight or a body mass index (BMI) of at least 40 or a BMI of 35 with comorbidities. *GP( @ r UQ T9 vomiting, esophageal spasm); Band slippage and/or prolapse that cannot be corrected with manipulation or adjustment; Stricture/stenosis with dysphagia, solid food intolerance and/or severe reflux; Non-absorption resulting in hypocalcemia or malnutrition; Weight loss of 20 percent or more below ideal body weight. endobj Fellow, American Society for Metabolic and Bariatric Surgery; SJ Magazine "Top Docs" - 2014, 2015, 2016, 2019, 2020, 2021, 2022; South Jersey Magazine "Best Doctors . endobj If you are a Highmark member, please review and discuss any questions regarding medical policies with your treating provider and refer to your specific . Is a Second Weight Loss Surgery Covered if Gastric Banding Didnt Work? Weight loss is only one of the many health benefits of Bariatric surgery, but to consider the weight loss successful, patients must keep the weight off for a minimum of five years with the help of proper diet and regular exercise. *GP( @ r UQ T9 However, coverage and payment for these services depends on the type of provider submitting the claim, the procedure/service and diagnosis codes submitted, and the patient's contract with Blue Cross. Provider Discharge Form. *GP( @ r UQ T9 Obesity is an increase in body weight beyond the limitation of skeletal and physical requirements, as a result of excessive accumulation of fat in the body. Bariatric procedures not meeting the criteria as indicated in this policy are considered not medically necessary. Weight Loss Surgery Insurance Appeal Letter & The Appeals Process, Recovery from Gastric Sleeve What to Expect from Day 1. 3 0 obj 2022 Bariatric Surgery Coverage Announcements Summary . Full coverage for a weight loss surgery procedure will be provided to a patient with a Body Mass Index (BMI) over 40. outpatient follow-up. 6Nale{Aq;7Qy=1(tg?fd``{ X'@``} QT` Note: Designation as Blue Distinction Centers means these facilities' overall experience and aggregate data met objective criteria established in collaboration with expert clinicians' and leading professional organizations' recommendations. MyBlue offers online tools, resources and services for Blue Cross Blue Shield of Arizona Members, contracted brokers/consultants, healthcare professionals, and group benefit administrators. 2003 Blue Cross Blue Shield Association Technology Evaluation Center Assessment. Access Your Payment Options. ObesityCoverage strongly feels that morbid obesity is a disease and every insurance company should cover these life saving procedures. *GP( @ r UQ T9 The BDC for Bariatric Surgery program evaluates facilities with bariatric surgery programs that treat adult patients 18 years or older, in Comprehensive Center (with or without an on- site ICU) and Ambulatory Surgery Center (ASC) settings. InterQual criteria is used to evaluate whether a medical procedure or equipment . One option is Adobe Reader which has a built-in reader. October 2017. 2 years after the original weight loss surgery, weight loss is still less than 50% of pre-operative excess body weight and weight remains at least 30% of the patients ideal body weight, per BMI. Blue Distinction Centers for Bariatric Surgery, along with the Blue Distinction Centers for Cardiac Care, Blue Distinction Centers for Knee and Hip Replacement, Blue Distinction Centers for Maternity Care, Blue Distinction Centers for Spine Surgery, Blue Distinction Centers for Substance Use Treatment and Recovery and Blue Distinction Centers for Transplants are a key part of our efforts to work with doctors and facilities to improve the overall quality, and resulting affordability of specialty care. Bariatric Journal is the leading bariatric surgery resource site for patients. If a patient is less than 18 years of age, a letter should be provided from a physician stating that surgery may prove risky if withheld for a later date. "Dental necessity" or "dentally necessary" means or describes a dental service that a dental care provider, exercising prudent clinical judgment, would provide to a covered person for the purpose of evaluating, diagnosing or treating a dental illness . In addition, some sites may require you to agree to their terms of use and privacy policy. Blue Distinction. *GP( @ r UQ T9 *GP( @ r UQ T9 In general, 20 percent to 30 percent above 'ideal' bodyweight, according to standard life insurance tables, constitutes obesity. In addition, some sites may require you to agree to their terms of use and privacy policy. VII. 13 0 obj This Program aligns with the Metabolic and Bariatric Surgery Accreditation and Quality Improvement *GP( @ r UQ T9 Blue Cross and Blue Shield of Illinois, aDivision of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association, PDF File is in portable document format (PDF). Services Provided by a Hospital or Other Facility, and Ambulance Services Blue Distinction Specialty Care . *GP( @ r UQ T9 ; . *GP( @ r UQ T9 `FlM->e4m[OQ[M49%^B-:qfI_xEk/rMaEvA:Q9IZTq('IfPp(TM|:m)eoYZ2wtguH"tzxgf=JLu)RyN0 Laparoscopic Gastric Bypass This procedure is performed laparoscopically, an approach that is less invasive than open incision surgery, where the surgeon staplesthe top portion of the stomach to separate it from the bottom part to create a small stomach pouch thatrestricts food intake the number of calories and nutrients the body absorbs. It is important to know that your employer can typically opt-out of weight loss surgery insurance coverage for their employees policies. Access Your Payment Options. *GP( @ r UQ T9 endstream *GP( @ r UQ T9 Morbid obesity is defined as a body mass index (BMI) greater than 40 kg/m2 or a BMI greater than 35 kg/m2 with associated complications including, but not limited to, diabetes, hypertension, or obstructive sleep apnea. This website uses cookies to improve your experience. *GP( @ r UQ T9 <> Morbid obesity is further defined as a condition of . The Pouch Reset Losing Weight After Weight Regain, Expected Weight Loss From Gastric Sleeve Surgery Calculator, Recovery From Gastric Sleeve What To Expect From Day 1, Before And After Your Gastric Balloon [Complete Guide], 5 Ways to Prevent Stretching Your Stomach After Gastric Bypass. *GP( @ r UQ T9 *GP( @ r UQ T9 <> Which Bariatric Surgery is Best? *GP( @ r UQ T9 In general, 20% to 30% above "ideal" bodyweight, according to standard life insurance tables, constitutes obesity. The patient meets one of the following age requirements: a. Fargo, N.D., 58121. To view this file, you may need to install a PDF reader program. This is true only if youve had a previous adjustable gastric banding procedure that met all of the criteria laid out for that procedure. Referral for Applied Behavioral Analysis (ABA) Assessment, Initiation and Continuation Request Form for Applied Behavior Analysis. As a result, some centers require active participation in a formal weight reduction program that includes frequent documentation of weight, dietary regimen, and exercise. One of the most common questions asked by prospective patients is, "Will my insurance cover Weight Loss Surgery, and what requirements do I have to meet in order to qualify?". Blue Cross and Blue Shield is an association of . Sleeve gastrectomy is an eligible procedure as a first stage of a two-stage procedure or as a sole definitive procedure; Laparoscopic adjustable gastric banding using an FDA approved adjustable gastric band: Laparoscopic adjustable banding is an eligible procedure ONLY when a contraindication to biliopancreatic bypass with duodenal switch, Rou-en-Y gastric bypass, and sleeve gastrectomy is documented in the medical record. . ,_*:1Ch_WpK3R6UYo gD_){6^9V0ljRoZY=;~lov'xmv'}y3-{lZjUTi:hnS: ]}}_v$j&m.~.?NIcWX*}pO=-f)/QeQ7vuT'UJ_\}Sj}NU~WOT}J"^ The Center of Excellence should be certified by the American College of Surgeons as a level 1 bariatric surgery center. However, there is a lack of evidence on the optimal timing, intensity and duration of nonsurgical attempts at weight loss, and whether a medical weight loss program immediately preceding surgery improves outcomes; The individual must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. Morbid obesity is further defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. patient education. Blue Cross Blue Shield of Michigan covers weight loss surgery. 2 0 obj *GP( @ r UQ T9 *GP( @ r UQ T9 National Range: $11,550 - $27,325+. Laparoscopic adjustable gastric banding using an FDA-approved adjustable gastric band is a second-tier procedure that shouldONLYbe performed when extenuating circumstances exist. Weight loss surgery is an effective treatment for morbid obesity. *GP( @ r UQ T9 The letter should also state that the physician has evaluated the patients mental condition and he/she is fully prepared for the surgery. *GP( @ r UQ T9 This site complies with the HONcode standard for trustworthy health information: Verify here. Learn more about weight loss surgery at Rocky Mountain Associated Physicians www.RMAP.com (801) 268-3800. Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association, serving residents and business in North Dakota. Most PDF readers are a free download. This website uses cookies to improve your experience. *GP( @ r UQ T9 The following bariatric procedures may be considered medically necessary for the surgical treatment of morbid obesity whenALLof the selection criteria are met. *GP( @ r UQ T9 As a result, some centers require active participation in a formal weight reduction program that includes frequent documentation of weight, dietary regimen, and exercise. Any bariatric surgeon that accepts Blue Cross Blue Shield of Michigan will know where the surgery has to take place. *GP( @ r UQ T9 *GP( @ r UQ T9 endobj | We'll assume you're ok with this, but you can opt-out if you wish. 2. The individual should have documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure. Directory ofBlue Distinction Centers and Blue Distinction Centers+ for Bariatric Surgery, Program Selection Criteria For Bariatric Surgery. *GP( @ r UQ T9 *GP( @ r UQ T9 Copyright 2022 Bariatric Journal, All Rights Reserved. and . stream Covered Diagnosis Codes for Procedure Codes: 43644, 43770, 43775, 43843, 43846, and S2083, Covered Diagnosis Codes for Procedure Code: 43845, Internal Medical Policy Committee 3-16-2020 Revision, Internal Medical Policy Committee 11-19-2020 Revision, Internal Medical Policy Committee 11-23-2021 Revision. <> ;.SovgPmc0u Ut9p+o1)ddT,c2MXy`PO;V kFXn^n1=u C5UL|efWaXenAFKua{ %,U(>t~;xL*[lMfl/$"Rg: >ArMT+&9!-Aa(=Xj _i5j)tpJh$D':uZ;yz.1KLLF Policy: 7.01.47 Effective Date: Nov. 1, 2022 Last Revised: Jan. 1, 2023 Replaces: 7.01.47 RELATED MEDICAL POLICIES: 2.01.38 Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease 7.01.522 Gastric Electrical Stimulation . Bariatric Journal does not provide medical advice, diagnosis, nor treatment. Check with your employer to find out how much they contribute toward your premium. The criteria for selection to the Blue Distinction and Blue Distinction Centers+ for Bariatric Surgery program were developed with input from physician experts and medical organizations and include a comprehensive evaluation of structure, process and outcome measures. Before calling make sure you see our questions to ask before calling your insurance company. 24/7 online access to account transactions and other useful resources, help to ensure that your account information is available to you any time of the day or night. What is a Weight Loss Seminar? The individual is morbidly obese and is at least 18 years of age. The items below are the minimum necessary for approval of your weight loss surgery. This policy version was replaced October 31, 2022. . 6/2022 . The following bariatric procedures are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. National Average: $19,450. when Blue Cross and Blue Shield Service Benefit Plan Surgical Procedures FBF22.05b.1 Page 3 of 5 1/1/2020 Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the pre-surgical requirements listed below. The following are three types of weight loss procedures that are covered by BCBS Alabama. <> Blue Distinction Centers for Bariatric Surgery, along with the Blue Distinction Centers for Cardiac Care, Blue Distinction Centers for Knee and Hip Replacement, Blue Distinction Centers for Maternity Care, Blue Distinction Centers for Spine Surgery, Blue Distinction Centers for Substance Use Treatment and Recovery and Blue Distinction Centers for Transplants are a key part of our efforts to work with doctors and facilities to improve the overall quality, and resulting affordability of specialty care. Enteric fistula that does not close with bowel rest and nutritional support; Gastrogastric fistula associated with ulcers, gastroesophageal reflux disease (GERD) and weight gain; Disruption/anastomotic leakage of a suture/staple line; Band intolerance with obstructive symptoms (e.g. As a result, some centers require active participation in a formal weight reduction program that includes frequent documentation of weight, dietary regimen, and exercise. Torrance Bariatric Institute provides expert weight loss procedures for patients looking for bariatric surgery in Torrance and surrounding areas. *GP( @ r UQ T9 You can also locate a contact number and email address on their website after choosing your state. The individual's understanding of the procedure and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure. Below, you'll learn what factors into the cost of . The Horizon Info Submission Template for Practitioners is another possible you can use to makes updates to your purveyor data in our systems. Blue Distinction Centers and Blue Distinction Centers+ for Bariatric Surgery offer a full range of bariatric surgery care, including: These centers have lower complication rates and fewer readmissions. Learn about BCBS of Alabama's requirements for weight-loss surgery. Individual outcomes may vary. Bariatric Journal Editor. Does Blue Cross Blue Shield of Alabama (BCBS) cover bariatric surgery? For more information, please contact SKYGEN USA 1-855-878-5368. Will Your Stomach Stretch after Gastric Sleeve Surgery? Yes, weight loss surgery must be done at a. *GP( @ r UQ T9 %PDF-1.6 % Returning Shopper? Bariatric surgery may be indicated for patients 18 to 60 years of age.
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