Insurance Criteria
Insurance Requirements
This is a general outline of insurance requirements. Please contact your insurance company to verify individual benefits for bariatric surgery. Our staff includes insurance coordinators who can also be of assistance to help you through the process.
St. John SmartHealth
- Body Mass Index 40>, or Body Mass Index of 35> with co-morbidities
- Minimum of 6 consecutive months of a physician monitored supervised weight loss program within 2 years prior to surgery.
- Nutrition Evaluation
- Psychological Evaluation
- Letter of Support from Primary Care Physician
Attention SmartHealth associates, please refer to the following website: http://www.smarthealth-mi.org/ regarding new insurance information. Bariatric surgery will be covered under Tier 1 and will not be covered under Tier 2. The website above can provide you with more additional information.
UHC
- Body Mass Index of 40> with or without co-morbidities or a Body Mass Index 35> with co-morbidities
- 5 years of physician notes showing morbid obesity. At least 1 year of progress notes showing participation in a medically supervised weight loss program that includes diet, exercise and behavioral modification.
- Psychological evaluation
- Letter Of Medical Necessity
- Letter of Support from Primary Care Physician
- Nutrition Evaluation
BCBS MI
- Body Mass Index of 50> no weight loss documentation required
- Body Mass Index of 35-49 must have 6 consecutive months of a supervised weight loss program within the last four years prior to the recommendation for bariatric surgery
- Letter of Support from Primary Care Physician
- Psychological evaluation
- Letter Of Medical Necessity
- Nutrition Evaluation
BCBS MESSA
- Does not require certain time length of diet documentation
- Body Mass Index of 35> and list of co-morbid conditions
- Nutrition Evaluation
- Letter Of Medical Necessity
- Psychological Evaluation
- Letter Of Support from Primary Care Physician
BCBS FEP
- Must weigh 100lbs over ideal body weight
- Psychological Evaluation
- Nutrition Evaluation
- Letter Of Medical Necessity
- Letter Of Support from Primary Care Physician
UniCare
- Body Mass Index of 40> or Body Mass Index of 35> with co-morbidities
- Patient must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery.
- Psychological Evaluation
- Letter Of Medical Necessity
- Nutrition Evaluation
- Letter of Support from Primary Care Physician
Total Health Care
- Body Mass Index of 40> with 2 life threatening co-morbidities or Body Mass Index of 45> with at least 1 life threatening co-morbidity
- Referral by primary care physician
- Documented compliance with a weight loss regimen as outlined including diet, exercise, and behavioral modification for a minimum of one year
- Nutritional counseling with supportive documentation for 6-9 months
- Psychological evaluation/assessment over 6-9 months to show stability and the ability to comply with post-operative limitations and requirements
- Documentation of a mild to moderate exercise program as tolerated 6-9 months or more
- Letter Of Medical Necessity
- Letter of Support from Primary Care Physician
Cigna
- Body Mass Index of 40> or Body Mass Index of 35> with atleast one co-morbidity
- Active participation within the last 2 years in one physician-directed weight-management for a minimum of 6 months without significant gaps. Program must include: vital signs, including weight, current dietary program, physical activity, behavioral interventions and pharmacotherapy weight-loss drugs if appropriate
- Psychological Evaluation
- Letter Of Medical Necessity
- Letter of Support from Primary Care Physician
- Nutritional Evaluation
Aetna
- Body Mass Index 40> or Body Mass Index of 35> with co-morbidities
- Letter Of Medical Necessity
- Psychological Evaluation
- Letter of Support from Primary Care Physician
- Member has attempted weight loss in the past without successful long-term weight reduction and member must meet either criteria
(a) Physician-supervised nutrition and exercise program (must be for a cumulative total of 6 months or longer in duration and occur within 2 years prior to surgery) or
(b) multidisciplinary surgical preparatory regimen (must be a regimen of at least 3 months duration)
- Nutritional Evaluation
Coventry/Omnicare
- Body Mass Index of 40> or Body Mass Index of 35> with co-morbidities
- Patient has failed to lose weight or has regained weight despite participation in a three month physician-supervised multidisciplinary program within the last 6 months that included: dietary therapy, physical activity and behavior therapy and support
- Psychological Evaluation
- Documentation that morbid obesity has persisted for atleast 3 years
- Nutritional Evaluation
- Cardiac Clearance if Phen-fen or Redux use in past
- Pulmonary clearance if clinically indicated
- Letter Of Medical Necessity
- Letter of Support from Primary Care Physician
Straight Medicaid
- Body Mass Index 40> with 2 life-threatening co-morbidities
- Must have at least a 6-month attempt at non-surgical supervised weight loss documented in medical records
- Copy of last 3 years medical records that document past dieting attempts and health conditions from Primary Care Physician, Specialists, Hospitals and Weight Loss Facilities
- Nutritional Evaluation
- Psychological Evaluation
- Letter Of Medical Necessity
- Letter of Support from Primary Care Physician
CareChoices/Preferred Choices
- Body Mass Index 40> or Body Mass Index 35> with co-morbidities
- Documentation that the Primary Care Physician supervised a weight loss program for a minimum continuous duration of 12 months and included diet and exercise. At least 6 office visits during the continuous 12-month period must include in the office notes the patients obesity and weight-related conditions, patients weight, history, physical findings, physicians assessment and treatment/recommendations/plans.
- Psychological Evaluation
- Nutritional Evaluation
- Letter of Support from Primary Care Physician
- Letter Of Medical Necessity
Great Lakes Health Plan
- Body Mass Index of 40> or Body Mass Index of 35> with two or more life threatening co-morbidities
- Documented compliance with weight loss program including diet, exercise, and behavioral modification for a minimum of one year.
- Psychological evaluation
- Referral by primary care physician
- Letter of Support from Primary Care Physician
- Letter of Medical Necessity
- Nutritional Evaluation
Meritain Insurance
- Body Mass Index 35> and list of co-morbidities
- Documentation of 6 consecutive month supervised weight loss program. Documentation must include: height, weight, Body Mass Index, co-morbid conditions, list of medications taken, detailed list of failed diet attempts in the past
- Psychological Evaluation
- Nutritional Evaluation
- Cardiac Clearance
- Pulmonary Clearance
- Thyroid Profile
- Letter of Medial Necessity
- Letter of Support from Primary Care Physician
Medicare
- Body Mass Index of 35> with at least one co-morbidity related to obesity
- Documentation that the patient has been previously unsuccessful with weight loss attempts and treatment for obesity
- Letter of Medical Necessity
- Psychological Evaluation
- Nutritional Evaluation
- Letter of Support from Primary Care Physician
OHIP
- Primary Care Physician must submit all information to OHIP for pre-authorization for bariatric surgery consult and bariatric surgery
- Three year medical history with progress notes, diagnostic testing, and labs
- Psychological Evaluation
- Letter of Medical Necessity
- Nutritional Evaluation
- Letter of Support from all doctor’s the patient is currently seeing
NGS-PPOM
- Body Mass Index of 40> or Body Mass Index of 35> with list of co-morbidities
- Letter of Medical Necessity
- Psychological Evaluation
- 12 months of weight loss documentation
- Nutritional Evaluation
- Letter of Support from Primary Care Physician
Smart Network
- Body Mass Index of 40> or Body Mass Index of 35> with co-morbidities
- Letter of Medical Necessity
- Pre-operative clearance by Primary Care Physician
- Psychological Evaluation
- Nutritional Evaluation
- Documentation that the patient has participated in a 12-week weight loss program, weekly or bi-weekly, within the last 12 months.
- Documentation stating the patient has been morbidly obese for 3 years or longer
- Physician records documenting co-morbid conditions and medications along with documentation that a true co-morbidity has failed appropriate medical therapy
- Letter of Support from Primary Care Physician
Molina
- Body Mass Index 40> or Body Mass Index 35> with life threatening co-morbidities
- Patient has participated in a physician supervised weight loss program involving diet, exercise and behavioral modification for a minimum of one year within the last two years.
- Psychological Evaluation
- Nutritional Evaluation
- Letter of Support from Primary Care Physician
- Letter of Medical Necessity
Midwest
- Referral required from Primary Care Physician to see specialist in-network
- Body Mass Index of 40> or Body Mass Index 35> with at least 2 life threatening co-morbidities
- Patient has participated in a medically supervised weight loss program including diet, exercise, and behavioral modification for a minimum of six months.
- Nutritional Evaluation
- Psychological Evaluation
- Letter of Medical Necessity
- Referral from Primary Care Physician
- Letter of Support from Primary Care Physician
Blue Care Network
- Body Mass Index of 40> or Body Mass Index 35> with co-morbid condition(s) related to obesity.
- Letter of Support from Primary Care Physician
- Patient has participated in a supervised weight loss program for a minimum of 6 consecutive months that includes diet, exercise, behavioral modification and pharmacotherapy within the last 4 years. Weight loss program is waived for patients with a Body Mass Index 50>
- Psychological Evaluation
- Nutritional Evaluation
- Letter of Medical Necessity
- Referral from Primary Care Physician
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