The individual continues to meet all the medical necessity criteria for bariatric surgery (see page 1) and.
Repeat surgical procedures for revision or conversion to another surgical procedure (that is also considered medically necessary within this document) for inadequate weight loss, * (i.e., unrelated to a surgical complication of a prior procedure) are considered medically necessary when all the following criteria are met: Surgical repair following gastric bypass and gastric restrictive procedures is considered medically necessary when there is documentation of a surgical complication related to the original surgery, such as a fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band herniation, or pouch enlargement due to vomiting. The candidate's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed.The candidate's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling and.The individual has received a thorough explanation of the risks, benefits, and uncertainties of the procedure and.The individual has undergone a preoperative mental health assessment and is felt to be an acceptable candidate and.The individual has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate and.The candidate's post-operative expectations have been addressed and.The individual's psychiatric profile is such that the candidate is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements and.The physician requesting authorization for the surgery must confirm the following:.The individual must have actively participated in non-surgical methods of weight reduction these efforts must be fully appraised by the physician requesting authorization for surgery AND.life threatening cardio-pulmonary problems, (e.g., severe sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy) AND.BMI of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to:.Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band ® System or the REALIZE ™ Adjustable Gastric Band), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria: This document addresses those procedures. There are a variety of surgical procedures intended for the treatment of clinically severe obesity. HIs specialty is the DS and the PPO covers it.unless the employer negotiates for less coverage.Ĭlinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. And you DO know that you are in the back yard of one of hte best bariatric surgeons on the planet, right? Keshishian.
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