BCBS of Vermont Weight Loss Surgery – How to Avoid a Denial

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

1. Be age 18 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. To determine whether or not patients have responded to conservative measures for weight reduction, patients must have been active participants in non-surgical weight reduction programs that include frequent, e.g., monthly, documentation of weight, dietary regimen, and exercise. In general, patients must have participated in these programs for at least 6 months. These conservative attempts must be reviewed by the practitioner seeking approval for the surgical procedure.
4. The patient has participated in at least one medically supervised attempt to lose weight within the 2 years preceding surgery. The medically supervised weight loss attempt(s) must include at least six monthly medical visits over six consecutive months with all visits under the direction of a medical doctor physicians’ assistant nurse practitioner or a registered dietitian supervised by an MD, DO, PA, or NP. The patient’s participation in a structured weight loss regimen must be documented in the medical record by an attending practitioner who supervised the patient’s progress. A physician’s notation alone is not sufficient documentation. Documentation should include medical records indicating the patient’s adherence to the current nutrition and exercise program throughout the course of the medically supervised weight loss regimen.
5. The patient must be evaluated preoperative by a licensed mental health provider (i.e. psychiatrist, licensed psychologist [PhD or MA] or licensed clinical social worker [LICSW]) to ensure the patient’s ability to understand, tolerate and comply with all phases of care and to ensure a commitment to long term follow-up requirements. The evaluation must document that any psychiatric, chemical dependency, or eating disorder contraindication to surgery have been ruled out.
6. The patient must have undergone an appropriate medical work up which may include upper gastrointestinal series, endoscopy, appropriate preoperative laboratory studies and EKG. A complete physical examination by the attending surgeon and an assessment of thyroid levels is required. If co-morbid conditions (i.e. diabetes or cardiovascular disease) are present, an appropriate evaluation of those conditions is required to ensure that patient is capable of undergoing the procedure.

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, and non-absorption resulting in hypoglycemia or malnutrition, weight loss of 20% or more below ideal body weight.

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.

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

• By Phone: (800) 247-2583
• Contact Blue Cross Blue Shield of Vermont
• Full Bariatric Surgery Medical Policy for Blue Cross Blue Shield of Vermont