BCBS of Kansas City Weight Loss Surgery – How to Avoid a Denial

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

1. Growth is completed (generally, growth is considered completed by 18 years of age)
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. Completion of the following:
• Physician records for the 12 months immediately preceding the request for bariatric surgery must be submitted. A physician’s summary letter is not sufficient documentation. The documentation should include the physician’s initial assessment, and subsequent assessment of progress at each visit documenting:
• The member’s participation in a physician-supervised nutrition and exercise program that includes dietician consultation, low calorie diet, increased physical activity, and behavioral modification for a total of at least 6 consecutive months within the 12 months prior to consideration for surgery
• Weight loss attempts (diet, exercise, medication, etc.) including the length of time for each method at the weight loss attained
• Medical records of the attending physician, which document the patient’s weight and progress at each visit, will be required for review
• Co-morbid conditions including treatment for those conditions
• The member must have attempted weight loss in the past without successful long-term weight reduction
• For members participating in a physician-administered nutrition and exercise program (e.g. OptiFast, MediFast), program records that document participation and progress, may substitute for the physician’s medical records
4. If the member has been pregnant, she must be at least 12 months post-partum from the date of receipt of the application for the surgery
5. The Blue KC Bariatric Surgery Questionnaire (included at the end of this policy) must be completed, with all required attachments, and submitted for review
6. After qualifying for surgery based on the guidelines above, and for three months immediately prior to the surgery, the member must participate in a physician directed organized multidisciplinary surgical preparatory regimen meeting all of the following criteria in order to improve surgical outcomes, reduce the potential for surgical complications and establish the member’s ability to comply with post-operative medical care and dietary restrictions:
• Consultation with a dietician or nutritionist
• Reduced-calorie diet program supervised by dietician or nutritionist
• Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional

Important note about physician summary letters

A physician’s summary letter, without evidence of contemporaneous oversight is not sufficient documentation.

Documentation should include medical records of the physician’s initial assessment of the member, and the physician’s assessment of the member’s progress at the completion of the multidisciplinary surgical preparatory regimen.

• Behavior modification program supervised by qualified professional with lifestyle changes documented by all of the following:
• Loss of 5% of his/her body weight in the 3 months prior to surgery
• Diet record
• Documentation in the medical record of the member’s participation in the multidisciplinary surgical preparatory regimen at each visit
7. Documentation of social support prior to and after the surgery
8. Documentation indicating the patient is willing to commit to long-term follow up and be compliant with recommendations

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 Considerations). In addition, any devices used for bariatric surgery must be in accordance with the FDA-approved indications for use.

Revision Requirements

Revision of a bariatric procedure may be medically necessary if it is addressing perioperative or late complications of the original procedure. 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

Revision of a primary bariatric procedure that has failed due to dilation of the gastric pouch (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 and the patient still meets criteria (BMI) for bariatric surgery.

Contact Blue Cross Blue Shield Kansas City to Ask About Bariatric Surgery

• By Phone: 816-395-3558
• Contact Blue Cross Blue Shield Kansas City
• Full Bariatric Surgery Medical Policy for Blue Cross Blue Shield Kansas City