Medical Insurance for LAP-BAND® and Gastric Bypass procedures in California
presented by the Coastal Center for Obesity for residents of Bellflower, Beverly Hills, Brentwood, Carson, Cerritos, Corona, Culver City, Downey, Glendale, Hermosa Beach, Hollywood, Hollywood Hills, La Mirada, Lakewood, Lawndale, Long Beach, Los Altos, Los Angeles, Marina del Rey, Moreno Valley, Norwalk, Ontario, Palms, Paramount, Pasadena, Playa del Rey, Playa Vista, Rancho Cucamonga, Rancho Palos Verdes, Redondo Beach, Riverside, Rolling Hills Estates, San Bernardino, San Pedro, Santa Monica, Torrance, Venice, West Hollywood, West Los Angeles, Westchester, and Whittier

Insurance for Weight Loss Surgery Approval Process:

Insurance company policies regarding coverage of bariatric surgery can vary widely. The information below is intended to answer some of your potential questions about our approval process.

Select your insurance company from the following links or scroll down to find your insurance's weight loss surgery coverage:

Aetna
Blue Cross of California
Blue Cross/Blue Shield
Blue Shield of California
CCN/First Health
Cigna

Great West
Health Net
Medicare
Prospect (Medical Group)
Tricare
United Healthcare

Aetna

What you need to know:

Patient needs to get 5 years progress notes from Primary Care Physician. Aetna will not start reviewing without that along with Letter Of Medical Necessity. They will look to make sure BMI (Body Mass Index) has met requirements for 5 years, verify co morbidities and make sure that they have done a 6 month physician supervised diet in the last 2 years with monthly weigh ins and notes about the diet. See below for more details. Make sure to get everything entered in their computer when calling for benefits because if things are sent without initiating it over the phone, they will disregard.

Requirements taken from the policy:
I.

1. Presence of severe obesity that has persisted for at least 5 years, defined as either:
   a. Body mass index (BMI (BODY MASS INDEX))* exceeding 40; or
   b. BMI (BODY MASS INDEX)* greater than 35 in conjunction with any of the following co-morbidities:
       i. coronary heart disease; or
       ii. type 2 diabetes mellitus; or
       iii. clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in Aetna CPB 004 - Obstructive Sleep Apnea: Diagnosis and Treatment); or
iv. medically refractory hypertension (blood pressure > 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);

and

2. Patient has completed growth (18 years of age or documentation of completion of bone growth); and
3. Member has attempted patient weight loss in the past without successful long-term weight reduction; and
4. Member must meet either criterion a (physician-supervised nutrition and exercise program) or criterion b (multidisciplinary surgical preparatory regimen):
a. Physician-supervised nutrition and exercise program: Member has participated in a physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record. This physician-supervised nutrition and exercise program must meet all of the following criteria:
      i. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
      ii. Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration, with participation in one program of at least three consecutive months, prior to the date of surgery. (Pre certification may be made prior to completion of nutrition and exercise program as long as a cumulative of six months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.); and
      iii. Nutrition and exercise program must occur within the two years prior to surgery; and
      iv. Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member's participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of physician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member's participation and progress may substitute for physician medical records;

or

b. Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, member must participate in an organized multidisciplinary surgical preparatory regimen of at least three months duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions:
    i. Consultation with a dietician or nutritionist; and
    ii. Reduced-calorie diet program supervised by dietician or nutritionist; and
    iii. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
    iv. Behavior modification program supervised by qualified professional; and
    v. Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment the member, and an assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.)

and

5. For members who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, a pre-operative psychological evaluation and clearance is necessary in order to exclude members who are unable to provide information consent or who are unable to comply with the pre- and postoperative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery.

Blue Cross of California

What you need to know:

They only need the Letter Of Medical Necessity unless they state otherwise when you call for benefits.

Requirements taken from the policy:

Morbid obesity has been defined as a body mass index greater than 40 or greater than 35 when co morbidities are present, including, but not limited to hypertension, obstructive sleep apnea or diabetes.

Blue Cross / Blue Shield

What you need to know:

This varies by state. You need to verify what is needed when you get benefits. Most of the time in addition to the Letter Of Medical Necessity, they want a History and Physical with their Primary Care Physician, History and Physical with the surgeon, a nutrition evaluation and a psychological evaluation or one or more of the above.

Blue Shield of California

What you need to know:

Patient needs to have History And Physical done with Primary Care Physician, Surgeon and have Psychological and Nutrition Evaluation. We can get the rest of the information from their questionnaire.

Requirements taken from the policy:

1. Current HISTORY AND PHYSICAL exam
2. Procedure number
3. Patient’s current height, weight and ideal weight
4. Patient’s age
5. Diet history
6. Contributing Medical Conditions (Diabetes, hypertension, Joint Pain, etc.)
7. Frame Size-small, medium, large
8. Body Mass Index (BMI (BODY MASS INDEX))
9. Multidisciplinary Team Consults (Medical, Surgical, Psychological and Nutritional)

CCN / First Health

What you need to know:

Many times they say it is not a covered benefit unless you specifically say when it is medically necessary. If we get them everything they need, it is medically necessary and they will cover it, but they are very strict with approvals.

Requirements taken from policy:

1. BMI (Body Mass Index), height and weight.
2. History And Physical to include co morbidities such as diabetes, coronary artery disease, hypertension, hyperlipidemia, obstructive sleep apnea, pulmonary hypertension, weight-related degenerative joint disease or lower extremity venous or lymphatic obstruction along with detailed management of these.
3. Documentation of failed medical dietary treatments including exercise and behavioral therapy.
4. Documentation of completion of bone growth. (This is when the patient is young, but it doesn’t specify age).
5. Weight loss programs must be documented by attending physician who does not perform the surgical procedure.
6. Evaluation by the provider or by a nutritionist or psychologist regarding the patient’s ability to follow post-treatment dietary program.

Cigna

What you need to know:

You need to get everything entered in their computer system when calling for benefits or they will not recognize it when it is sent to them. They are one of the strictest insurances.

Requirements taken from Policy:

They usually need 6 month physician supervised diet and a psychological evaluation, but this can vary by policy, so ask when checking benefits.

Great West

What you need to know:

Never send anything unless you have everything! They get mad if you send just the Letter Of Medical Necessity.
Steps:
1. Do eligibility and benefits.
2. Do Pre-certification, so patient is in their computer. Do not skip this or they will not recognize anything when it is sent in.
3. Send in the following:

Requirements taken from the policy:

1. They need have 40 BMI (Body Mass Index) for at least 3 years.
2. They need to be age 25-55.
3. They need to have a Psychological Evaluation.
4. They need to have an History And Physical and letter from their Primary Care Physician saying that they have had no alcohol habit for at least 1 year, that they do not have an endocrine or thyroid disorder, that they have failed at least a 6 month diet in the last 2 years with diet, exercise and behavioral therapy.
5. They need to have a diet history personally filled out by the patient.

Health Net

What you need to know:

They will vary what they ask for. They always want a psychological evaluation and sometimes a nutrition evaluation and a dictated History And Physical. You need to check to be sure when calling for benefits. It will vary by policy.

Medicare

What you need to know:

We don’t need to get prior authorization like with every other insurance. The doctor’s review for medical necessity and decide if they can do it.

Requirements taken from the policy:

Gastric Bypass surgery for morbid obesity may be covered under the Medicare program if all the following conditions are met:
-The surgery is medically appropriate for the patient,
-The patient is well informed, motivated, an acceptable operative risk, and is able to participate in treatment and long-term follow-up,
-The patient has a body mass index (BMI) of 35 kg/m2 or greater,
-The surgery is an integral and necessary part of a course of treatment for a patient with one of the following life threatening or disabling co-morbid conditions:

1. Poorly controlled type II diabetes mellitus
2. Poorly controlled dyslipidemia
3. Poorly controlled hypertension
4. Serious cardiopulmonary disorder (e.g. coronary artery disease, cardiomyopathy, pulmonary hypertension)
5. Obstructive sleep apnea
6. Severe arthropathy of weight-bearing joints (treatable but for the obesity)
7. Pseudotumor cerebri

-There is absence of active substance abuse or major uncontrolled psychiatric disorder.
Claims submitted for reimbursement for Gastric Bypass surgery will require submission of documentation to support the following criteria before payment will be considered:
1. The patient must have a BMI (Body Mass Index) greater than or equal to 35
2. Non-surgical methods of accomplishing weight reduction must have been attempted and documented. Interventions within 2 years of surgery should include all of the following:

• at least six months of a supervised diet. This should be a structured program with oversight by a physician and a registered dietician (RD), a board certified specialist in pediatric nutrition (CSP), or renal nutrition (CSR) or a fellow in the American Dietetic Association (FDA)
• Pharmacological management - at least one type of pharmacological management should be tried prior to surgery. This fact could be included in the surgeon's history of the patient's illness
• Evidence of dietary supervision by a physician and dietician and a trial of pharmacological management must be present in the medical records. Oversight should be evidenced by at least monthly visits to the physician and/or dietician

1. Psychological assessment by a licensed clinical psychologist or psychiatrist including administration of the Minnesota Multi Personality Inventory (MMPI) should be documented. This should occur prior to the decision to operate. It may have occurred a year or more before the operation of bariatric surgery is considered. Bariatric surgery will permanently change a person's lifestyle. After bariatric surgery, the individual will not be able to eat what is considered to be a normal meal. The surgeon should investigate whether or not the patient psychologically will adapt to the change, which will result from bariatric surgery. The patient should be evaluated for depression, anxiety, substance abuse or other psychiatric risks prior to the decision to operate is made. Axis 1, clinical disorders and conditions, which may be the focus of clinical assessment and treatment, should be successfully managed before surgery.

2. A letter of medical necessity from the surgeon explaining the patient's illnesses and the conditions aggravated by the obesity.

Prospect (Medical Group)

What you need to know:

Patients need to have a referral.

Requirements taken from the policy:

1. Presence of Morbid Obesity for 5 years BMI (Body Mass Index) over 40, 100 lbs over ideal wt or BMI (Body Mass Index) over 35 with Coronary Heart Disease, Type 2 Diabetes, or 3 or more of the following: Hypertension, Low density lipoprotein cholesterol, current cigarette smoking, impaired glucose tolerance, family history of cardiovascular disease, age over 45 in men or 55 in women.
2. Patient has completed growth (18 years or documentation)
3. Diet history (6 month physician supervised in the last year)

Tricare

What you need to know:

They are one of the easiest fastest to approve. Make sure to include authorization sheet or they will disregard.

Taken from policy:
1. A patient is 100 pounds or more over the ideal weight for height and body structure, and has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian Syndrome (and other severe respiratory diseases), hypothalamic disorders, and severe arthritis of the weight-bearing joints.
2. A patient is 200 percent or more of the ideal weight for height and body structure. An associated medical condition is not required for this category.

United Healthcare

What you need to know:

You need to get everything entered in their computer system when calling for benefits or they will not recognize it when it is sent to them. They are very slow and you have to stay on them about authorizations or they will let stuff sit for months. You have to call on each individual and get the requirements. It will vary by policy.

Need more information about health care / insurance coverage for Gastric Bypass and LAP-BAND® procedures? Call the Coastal Obesity Insurance Specialists at (888) 527 5222 or email them at coastalinfo@coastalobesity.com