BCBS of North Carolina Weight Loss Surgery – How to Avoid a Denial

Adults Only

In order to be approved by Blue Cross Blue Shield North Carolina for bariatric surgery in the United States, you must meet the following criteria:

1. Diagnosis of Morbid obesity, defined as
• a Body Mass Index (BMI) greater than 40

Or

• have a BMI > 35 associated with at least one or more of the fol lowing problems which are generally expected to be improved, curtailed or reversed by surgical treatment:
• The obesity interferes with daily function to the extent that performance is severely curtailed (i.e., impending job loss or job loss with documented disability)
• The obesity causes incapacitating pain and limitation of motion in any weight-bearing joint or the lumbosacral spine documented by physical examination in association with radiologic findings showing degenerative osteoarthritis
• There is significant respiratory insufficiency as evidenced by pCO2 > 50 mmHg, hypoxemia at rest, as evidenced by pO2 < 55 mmHg on room air; FEV 1/FVC < 65%, or DLCO < 60% (e.g., Obesity Hypoventilation Syndrome)
• Clinically significant obstructive sleep apnea (i.e., Patient meets criteria for treatment of obstructive sleep apnea set forth in a separate policy, titled Sleep Apnea : Diagnosis and Medical Management
• Type 2 diabetes mellitus
• Documented coronary artery disease
• Cardiomyopathy
• Heart failure
• Gastroesophageal reflux disease with secondary asthma or erosive esophagitis not controlled despite maximum dosages of proton pump inhibitors
• Pseudotumor cerebri
• Patient has at least one of the following:
• Medically refractory hypertension (blood pressure > 140 mmHg systolic and/or > 90 mmHg diastolic measured with appropriate size cuff) that has not responded to medical management including at least two (2) anti-hypertensive drugs at maximum tolerated dosages
• First degree relative with premature (age < 50) cardiovascular disease
• Hypercholesterolemia > 240 mg/dL or hypertriglyceridemia > 400 mg/dL or low density lipoprotein (LDL) > 160 mg/dL or high density lipoprotein (HDL) < 40 mg/dL ; despite appropriate medical therapy defined as at least one appropriate drug at maximum dosage
• Metabolic syndrome
• Pulmonary hypertension
• The patient has no specifically correctable cause for the obesity, e.g., an endocrine disorder
• A thorough evaluation has been documented to assess the patient’s suitability for surgery and their ability to comply with lifelong follow up
• Surgery for morbid obesity is eligible for coverage when it is part of a comprehensive pre-surgical, surgical and post-surgical program

Use this BMI Calculator to check your body mass index…

Adults & Adolescents

A thorough preoperative evaluation for surgery for morbid obesity must include all of the following:

1. Evaluation of the patient’s understanding of the procedure to be performed, including the procedure’s risks and benefits, length of stay in the hospital, behavioral changes required prior to and after the surgical procedure (including dietary and exercise requirements), follow up requirements with the performing surgeon, and anticipated psychological changes
2. Evaluation of the patient’s family/caregivers support and understanding of the information in #1
3. Within 12 months prior to surgery, a thorough nutritional evaluation by a physician, registered dietician, or other licensed professional experienced in the issues of bariatric surgery, who has had a meaningful conversation with the individual regarding the dietary and lifestyle changes required to ensure a successful outcome over time. Nutritional assessment must follow American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines. Pre-operative assessment must document that the patient has a good understanding of the diet and nutritional changes that are associated with bariatric surgery and has the capacity to comply with these changes. Per the ASMBS guidelines, “…it is essential to determine any preexisting nutritional deficiencies, develop appropriate dietary interventions for correction, and create a plan for postoperative dietary intake that will enhance the likelihood of success. Not only should the practitioner review the standard assessment components (i.e., medical co – morbidities, weight history, laboratory values, and nutritional intake ), it is also important to evaluate other issues that could affect nutrient status, including readiness for change, realistic goal setting, general nutrition knowledge, as well as behavioral, cultural, psychosocial, and economic issues”
4. Evaluation by a licensed psychologist, psychiatrist or licensed clinical social worker that documents the absence of significant psychopathology that can limit the patient’s understanding of the procedure or the ability to comply with medical/surgical recommendations and to adhere to required lifestyle modifications and follow up/ social support. Documentation from that evaluation must include the patient’s suitability for the proposed bariatric surgery and the lifetime commitment required for a successful outcome
5. Appropriate medical workup may include a chest x-ray, upper gastrointestinal series, endoscopy, appropriate pre-op labs and ECG. A complete physical examination by the attending surgeon and an assessment of thyroid levels is required. If the patient has comorbid conditions (e.g. diabetes or cardiovascular disease) the patient must be capable of undergoing the procedure
6. Anesthesia clearance for surgery

Blue Cross Blue Shield North Carolina requires the first five criteria above to be met before seeking prior plan approval for adults and adolescents; the sixth must be met prior to surgery.

Surgical procedures must be performed at a facility capable of providing gastrointestinal and biliary surgery (preferably JCAHO accredited), AND that has equipment and staff capable of managing a morbidly obese patient (appropriate instruments, beds, lifts, monitoring equipment) AND that can manage short and long term complications of surgery for morbid obesity.

The performing surgeon must be qualified and experienced in performing the procedure to be undertaken.

Follow up programs must include regular follow up for at least five years , including postoperative nutrition follow-up.

Significant weight loss following surgery for morbid obesity can lead to redundant skin and fat folds in varied anatomic locations (e.g., breasts, medial upper arms, and medial thighs, lower abdominal area also called “abdominal apron” or pannus). Surgical removal of redundant skin and f at folds is generally considered cosmetic and is not covered. Coverage may be considered for panniculectomy in patients who meet criteria specified in separate policy, Abdominoplasty, Panniculectomy, and Lipectomy.

Limited evidence is available on bariatric surgery in patients with a BMI of less than 35. Case series report a high rate of remission of diabetes in undergoing gastric bypass surgery; however, bariatric surgery for diabetes in patients with a BMI less than 35 is not currently considered standard of care and is not supported in current specialty society guidelines. For patients without diabetes, there is limited evidence on outcomes of surgery and no evidence that health outcomes are improved.

Patients with a BMI greater than or equal to 50 kg/m 2 need a bariatric procedure to achieve greater weight loss. Thus, use of adjustable gastric banding, which results in less weight loss, should be most useful as one of the procedures used for patients with BMI less than 50 kg/m 2. Malabsorptive procedures, although they produce more dramatic weight loss, potentially result in nutritional complications, and the risks and benefits of these procedures must be carefully weighed in light of the treatment goals for each patient.

Prior to consideration of a second bariatric procedure , patients who have undergone adjustable gastric banding must demonstrate that appropriate band adjustments in conjunction with regular post – operative visits and nutritional compliance has failed to result in adequate weight loss.

Adolescents Only

Bariatric surgery in adolescents may be considered medically necessary according to the same weight-based criteria used for adults, but greater consideration should be given to psychosocial and informed consent issues. In addition, any devices used for bariatric surgery must be in accordance with the FDA-approved indications for use.

In addition to the weight-based criteria, there is greater emphasis on issues of developmental maturity, psychosocial status, and informed consent for adolescent patients. All guidelines mention these issues, but recommendations are not uniform for addressing them.

The Endocrine Society published recommendations for the following for prevention and treatment of pediatric obesity in 2008. These guidelines contained the following recommendations for bariatric surgery:

• The child has attained Tanner 4 or 5 pubertal development and final or near – final adult height
• The child has a BMI 50 kg/m 2 or has BMI above 40kg/m 2 and significant, severe comorbidities
• Severe obesity and comorbidities persist despite a formal program of lifestyle modification, with or without a trial of pharmacotherapy
• Psychological evaluation confirms the stability and competence of the family unit
• There is access to an experienced surgeon in a medical center employing a team capable of long-term follow-up of the metabolic and psychosocial needs of the patient and family, and the institution is either participating in a study of the outcome of bariatric surgery or sharing data
• The patient demonstrates the ability to adhere to the principles of healthy dietary and activity habits
• Bariatric surgery is not recommended for preadolescent children, for pregnant or breast-feeding adolescents, and for those planning to become pregnant within 2 years of surgery; for any patient who has not mastered the principles of healthy dietary and activity habits; for any patient with an unresolved eating disorder, untreated psychiatric disorder, or Prader-Willi syndrome

Revision Requirements

Revision surgery to address perioperative or late complications of the original bariatric procedure is considered medically necessary. These include, but are not limited to, staple-line failure, obstruction, stricture, erosion, non-absorption resulting in hypoglycemia or malnutrition, weight loss of 20% or more below ideal body weight, band herniation, and band slippage that cannot be corrected with manipulation or adjustments.

Revision of a primary bariatric procedure that has failed due to dilation of the gastric pouch or dilation proximal to an adjustable gastric band or other restrictive procedure (documented by upper gastrointestinal examination or endoscopy) is considered medically necessary if the initial procedure was successful in inducing weight loss prior to dilation, and the patient has been compliant with a prescribed nutrition and exercise program.

Repeat surgical procedures for revision or conversion to another surgical procedure (that is also considered medically necessary within this document) for inadequate weight loss, (that is, unrelated to a surgical complication of a prior procedure) are considered medically necessary when all the following criteria are met:

• The individual continues to meet all the medical necessity criteria for bariatric surgery, including current pre-operative nutritional assessment
• There is documentation of compliance with the previously prescribed postoperative dietary and exercise program
• Weight loss following the original surgery is less than 50% of pre-operative excess body weight and weight remains at least 30% over ideal body weight

Contact Blue Cross Blue Shield North Carolina to Ask About Bariatric Surgery

• By Phone: 1-888-471-2738
• Contact Blue Cross Blue Shield North Carolina
• Full Bariatric Surgery Medical Policy for Blue Cross Blue Shield North Carolina