Approval Criteria Checklist for Obesity Surgery*
A reference guide of standard obesity surgery coverage criteria
to assist you in selecting a benefit design plan that will meet your company’s needs
Candidate Qualifications for Surgery
Super Obese BMI ≥50
Extreme Obesity / Class III Obesity BMI ≥40
Obese/Class II Obesity BMI ≥35 – 39.9 with serious, co-morbid, medical conditions
Hypertension
Type II Diabetes Mellitus
Dyslipidemia
Musculoskeletal, neurological or body size problems precluding or severely impairing quality of life (employment, family function or ambulation)
Life-threatening Cardiopulmonary Problems (sleep apnea, obesity-hypoventilations syndrome or obesity-related cardiomyopathy)
Coronary Artery Disease
Obesity-Related Cardiomyopathy
Suggested Additional Candidate Qualifications for Surgery
Documentation that other methods of weight loss have been tried unsuccessfully
(e.g., changes in eating, behavior, increased physical activity and/or drug therapy)
Documentation that performing daily routine activities (e.g., work-related & family
functions) are not possible & quality of life is seriously impaired due to severity of
obesity
Documentation of a formal psychological evaluation demonstrating the patient is a
sound candidate for bariatric surgery & is able to adhere to post surgical behavior
management requirements
Documentation of 3 continuous months of compliance with medically supervised, nonsurgical weight reduction methods by PCP or bariatric surgeon
Documentation of a Pre-Surgery Evaluation: evaluations may vary based on patient
needs & surgeon preference but should at least include the following:
Medical (including clearance from primary care physician)
Surgery (by bariatric surgeon)
Cardiology (in selected patients to uncover potential heart disease & to determine
treatment as necessary)
Pulmonary (including a pulmonary function test & when indicated, a sleep apnea test)
Psychological or psychiatric
Endocrinology
Nutrition
Documentation of participation in a comprehensive Weight Management Program:
Must attend & comply with all outlined activities & visits as established by the bariatric
program. The Weight Management Program should Include, at Pre & Post Surgery,
these components:
____ Nutrition Education
____ Personalized Exercise Program
____ Psychological Evaluation
____ Support Groups
____ Appropriate Diet Supplementation
____ Surgery Education
____ Surgeon & RN Visits
____ Comprehensive Lab Work-ups
____ Bariatric Program Coordinator
____ Behavior Management Program
____ Family & Social Support System
DSL# 10-0179 ©2010 All rights reserved EREM027
*Compiled from multiple sources. See Reference List.
Approval Criteria Checklist for Obesity Surgery*
A reference guide of standard obesity surgery coverage criteria
to assist you in selecting a benefit design plan that will meet your company’s needs
Surgical Procedures
Open or Laparoscopic Roux-en-Y (gastric bypass)
STANDARD
PROCEDURES
LAGB (Laparoscopic Adjustable Gastric Band)
VBG (Vertical Banded Gastroplasty)
BPD (Biliopancreatic Diversion)
LSG (Laparoscopic Sleeve Gastrectomy)
INVESTIGATIONAL
PROCEDURES
Mini Gastric Bypass
Gastric Balloon
Provider Qualifications
Recognized COE (Center of Excellence/Center of Distinction) facility and/or surgeon
practice by either the Surgical Review Corporation (SRC), the American College of
Surgeons (ACS), Medicare & Medicaid Services (CMS) or a Health Plan, such as
Aetna, BCBS, CIGNA, UnitedHealthcare.
Rural Area Exception – See “Clarification Points” Section
Benefit Design Options
Limit coverage to Centers of Excellence facilities & surgeons as defined by CMS
(Medicare & Medicaid Services) the SRC, the ACS or health plan
Provide different patient co-insurance levels based on selecting COE facility or nonCOE facility
Consider employment tenure for bariatric surgery benefit to be accessed
Tie surgical benefit & COE program requirements in with company sponsored wellness
or obesity management programs
Provide a Post-Surgery Incentive Strategy
Some examples include:
Set up criteria for post-surgery maintenance & program adherence. With achievement
of “x number” of met criteria patient/employee may qualify for paid or partially paid postbariatric plastic surgery.
Set up criteria for post surgery maintenance & program adherence. With achievement
of “x number” of met criteria patient/employee may receive reimbursement dollars back
into their HSA account.
DSL# 10-0179 ©2010 All rights reserved
EREM027
*Compiled from multiple sources. See Reference List.
Approval Criteria Checklist for Obesity Surgery*
A reference guide of standard obesity surgery coverage criteria
to assist you in selecting a benefit design plan that will meet your company’s needs
Clarification Points
Other areas of discussion related to benefits design are listed below.
However, there is not sufficient clinical documentation to make a
recommendation. For each topic, a reference is included to assist with
decision-making.
Repeat Surgery
To include revisions, repeat surgeries and conversion surgeries
https://secure.preferredone.com/Shared/MedicalPolicy/MC_H003.pdf
California Association of Health Plans Consensus Statement; or National Health Plan
Medical Policies (cited below)
A. Conversion to another surgical procedure – including all of the following 1-3:
1. Failure to respond to initial gastric bypass
2. Original surgery was at least 2 years prior to repeat procedure
3. Documentation that patient has been enrolled in & compliant with the
previous postoperative program
B. Revision of obesity surgery due to documented surgical complication from the primary procedure that has not responded to medical treatment – including, but not limited
to, one of the following:
1. Obstruction
2. Stricture
3. Dilatation of gastric pouch (only if procedure was successful in inducing
weight loss prior to pouch dilatation)
4. Stoma dilation or stenosis
5. Stoma ulcer
6. Malnutrition
C. Take down (reversal) of obesity surgery (only if documented complication present)
Note: All requests for repeat obesity surgery for staple line breakdown must be
referred for physician review.
Rural Area COE Exception
It has been suggested that in rural areas where the volume requirements cannot be
made that the facility must be COE provisional status level with the SRC or Level II
status with the ACS.
http://bbthor.bcbsnd.com/Bulletins/Blue_Cross_Blue_Shield_ND_Medical_Policy/Bariatric_Surgery.htm
DSL# 10-0179 ©2010 All rights reserved
EREM027
*Compiled from multiple sources. See Reference List.
Approval Criteria Checklist for Obesity Surgery*
A reference guide of standard obesity surgery coverage criteria
to assist you in selecting a benefit design plan that will meet your company’s needs
Clarification Points
COE REQUIREMENTS
COE standard requirements vary among credentialing bodies but all address:
Surgical Volume & Training:
Usually a minimum of 125 surgeries per year/facility
Surgeon performed at least 125 total bariatric cases lifetime with at least 50 cases
performed in the preceding 12-month period
Processes in place for additional training & training of new surgeons brought into
practice
Medical Director:
Physician Medical Director for bariatric surgery who participates in the relevant decision-making administrative meetings of the institution
Trained Bariatric Staff & Program Extenders:
Utilization of a designated nurse or physician extender who are dedicated to serving
bariatric surgical patients & who are involved in the continuing education & care
of bariatric patients
Organized & supervised support groups for all patients who have undergone bariatric surgery at the institution
Program dedicated to a long-term patient follow-up goal of at least 75% at five years
for bariatric procedures with a monitoring & tracking system for outcomes
Equipment:
For the care of bariatric surgical patients including furniture, wheel chairs, operating
room tables, beds, radiologic capabilities, surgical instruments & other facilities
suitable for morbidly obese patients
Care Pathways:
Facilitate the standardization of perioperative care for the relevant procedure
Data Collection:
Collect & report outcomes for surgeon & facility
DSL# 10-0179 ©2010 All rights reserved
EREM027
*Compiled from multiple sources. See Reference List.
Approval Criteria Checklist for Obesity Surgery*
A reference guide of standard obesity surgery coverage criteria
to assist you in selecting a benefit design plan that will meet your company’s needs
References
1
Does Preoperative Weight Loss Predict Success with Laparoscopic Roux-en-Y Gastric Bypass.
Bariatric Times, April 2007
2
Oregon Health Resources Commission MedTAP Report June 2007
3
Sjostrom L, et.al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. NEJM 357
(8) August 23, 2007
4
Adams TD, et al. Long Term Mortality after Gastric Bypass Surgery. NEJM 357 (8) August 23,
2007
5
Bray GA. The Missing Link – Lose Weight, Live Longer. NEJM 357 (8) August 23, 2007
6
http://www.lapsurgery.com/BARIATRIC%20SURGERY/ASBS.htm
7
CMS National Coverage Decision: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=160
[online]
8
CMS Centers of Excellence List: www.cms.hhs.gov/center/coverage.asp [online]
9
National Institute of Health Consensus Statement on Bariatric Surgery: http://
consensus.nih.gov/1991/1991GISurgeryObesity084PDF.pdf [online]
10 http://www.anthem.com/medicalguidelines/va/f5/s10/t2/pw_037637.pdf [online]
11 https://www.unitedhealthcareonline.com/b2c/cmaIndexResult.do?
channelId=016228193392b010VgnVCM100000c520720a____&htmlFilePath=/ccmcontent/
ProviderII/UHC/enUS/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/MedicalPolicies/
Bariatric_Surgery.htm [online]
12 http://www.humana.com/providers/tools/provider_tools/clinical_healthcare.asp [online]
13 http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/
mm_0051_coveragepositioncriteria_bariatric_surgery.pdf [online]
14 http://www.aetna.com/cpb/medical/data/100_199/0157.html [online]
15 Bradley DW; Sharma C, Bal K. Centers of Excellence in Bariatric Surgery: Design, Implementation and One-Year Outcomes. Surgery for Obesity and Related Diseases, 2 (2006) 513-517
16 California Association of Health Plans: The Consensus Guidelines on Bariatric Surgery: CAHP
Obesity Initiative Workgroup. June 2006
17 http://bbthor.bcbsnd.com/Bulletins/Blue_Cross_Blue_Shield_ND_Medical_Policy/
Bariatric_Surgery.htm [online]
18 https://secure.preferredone.com/Shared/MedicalPolicy/MC_H003.pdf [online]
19 https://secure.preferredone.com/Shared/MedicalPolicy/MC_H003.pdf [online]
DSL# 10-0179 ©2010 All rights reserved
EREM027
*Compiled from multiple sources. See Reference List.