BCBS of New York Weight Loss Surgery – How to Avoid a Denial

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

1. Patient is 18 years of age or older
2. Diagnosis of Morbid obesity, defined as
• a Body Mass Index (BMI) greater than 40

Or

• BMI 35 – 39.9 AND one of the following
• Diabetes mellitus
• Obstructive sleep apnea
• Coronary artery disease
• Hypertension

Use this BMI Calculator to check your body mass index…

3. Patients should have documented failure to respond to conservative measures for weight reduction, prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure
• As a result, some centers require active participation in a formal weight reduction that includes frequent documentation of weight, dietary regimen, and exercise. However, there is lack of evidence on the optimal timing, intensity and duration of non-surgical attempts at weight loss, and whether a medical weight loss program immediately preceding surgery improves outcomes

Adolescents Requirements

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 (see Policy Guidelines). 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 following are examples from U.S. guidelines published since 2005 that address issues of maturity and psychosocial status:

• The Endocrine Society:
• The child has attained Tanner 4 or 5 pubertal development and final or near-final adult height
• Psychological evaluation confirms the stability and competence of the family unit
• The patient demonstrates the ability to adhere to the principles of healthy dietary and activity habits
• Institute for Clinical Systems Improvement:
• Recommendations for adolescents apply to “mature adolescents”, which is defined as having reached skeletal maturity
• Bariatric surgery in the adolescent patient is controversial and should be undertaken on a case-by-case basis in a high-volume bariatric surgery center

Revision Requirements

Revision surgery to address perioperative or late complications of a bariatric procedure is considered medically necessary. These include, but are not limited to:

• Staple-line failure
• Obstruction
• Stricture
• Non-absorption resulting in hypoglycemia or malnutrition, weight loss of 20% or more below ideal body weight
• Band slippage that cannot be corrected with manipulation or adjustment (see Policy Guidelines)

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

Blue Cross Blue Shield of New York Contact Information and Full Medical Policy on Bariatric Surgery

• By Phone:
• BCBS of Western New York: (800) 544-2583
• BCBS of Northeastern New York: (800) 888-1238
• More Contact Details:
• BCBS of Western New York
• BCBS of Northeastern New York
• Bariatric Surgery Coverage Criteria:
• BCBS of Western New York
• BCBS of Northeastern New York