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

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

1. Be age 18 years 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
• Uncontrolled type 2 diabetes
• Poorly controlled hypertension
• Obstructive sleep apnea
• Severe arthropathy of hips, knees, or lumbar spine
• Poorly controlled dyslipidemia
• Idiopathic Intracranial Hypertension (pseudotumor cerebri)

Use this BMI Calculator to check your body mass index…

3. There is documentation of 3 months of active participation in a diet and exercise program as recommended by the bariatric surgical multidisciplinary team. The scope and depth of this program is at the discretion of the bariatric surgical multidisciplinary team, and BCBSND does not specify the content of this program. There must be a second visit to the bariatric surgical team at least 3 months after the initial visit, and the subsequent visit must document the member’s active participation and adherence to the surgical team’s prescribed diet and exercise program. This documentation should contain specific data on weight, diet adherence, and exercise program adherence
4. Has not smoked for at least 3 months prior to surgery
5. Submission of a formal psychiatric evaluation by a licensed mental health provider who has appropriate working knowledge of the nature and mechanics of bariatric surgical procedures, knowledge of the psychology of eating and morbid obesity, and an understanding of the complexity with which these factors may manifest in the postoperative patient. ALL of the following must be documented by the mental health provider:
• Absence of current DSM-5 psychiatric disorder (including consideration of personality disorders, intellectual disabilities or neurocognitive disorders) which would hinder successful adherence with post-surgical weight loss regimen.
• Absence of active substance abuse within the past one yea

Adolecents 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.

Revision Requirements

Revision surgery, meaning, repositioning or removal of a lap-band device, reversal (“takedown”) of a prior restrictive or malabsorptive bariatric surgical procedure, revision of the initial procedure, or conversion from one type of procedure to another (eg, removal of lap-band and performance of sleeve at the same time), may be considered Medically Necessary when criteria the following criteria are met:

• The initial bariatric surgical procedure was a Covered Service as defined in their Benefit Plan
• There is adequate and complete clinical documentation in the medical record (e.g. radiologic studies, endoscopic reports, clinic notes) of one or more complications directly and proximately related to the initial bariatric surgical procedure, such as:
• Slipped lap-band
• Flipped lap-band port
• Broken lap-band device
• Erosion of lap-band
• Stoma ulcer
• Stoma dilation
• Pouch dilation
• Mechanical obstruction
• Stricture
• Non-absorption resulting in documented hypoglycemia or malnutrition
• Weight-loss of 20% or more below ideal body weight
• Staple-line failure
• Leakage
• Medically refractory gastroesophageal reflux, esophagitis, and/or vomiting, with or without hiatal hernia
• Infection around any implanted hardware
• Bleeding
• Severe dumping
• Failure of the primary procedure to achieve adequate weight loss, defined as failure to achieve weight loss of at least 25% excess body weight (25% EBW) at least two years out from the original procedure, when the clinical documentation shows that the member has been adhering to the post-bariatric-surgical aftercare plan regarding diet, nutrition, exercise and all required follow-up

Blue Cross Blue Shield of North Dakota Contact Information and Full Medical Policy on Bariatric Surgery

• By Phone: (800) 366-6888
• Contact Blue Cross Blue Shield of North Dakota
• Full Bariatric Surgery Medical Policy for Blue Cross Blue Shield of North Dakota