ConnectiCare Weight Loss Surgery – How to Avoid a Denial

In order to be approved by ConnectiCare for bariatric surgery in the United States, you must meet the following criteria:

1. The individual is age 18 or over
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
• (Obesity-related cardiomyopathy
• Obstructive Sleep Apnea (w/AHI >15)
• Pickwickian syndrome
• Respiratory insufficiency
• Hypoxia at rest
• Type II diabetes
• CAD
• Medically refractory hypertension

Use this BMI Calculator to check your body mass index…

3. A preoperative weight management program prepares an individual for postoperative dietary management and may improve surgical outcomes. Therefore, there must be documentation of at least one of the following:
• In the two years prior to the surgery, the individual has participated in a physician-supervised weight management program for a minimum of six months. Such a program must consist of dietary therapy (utilizing a dietician/nutritionist), a low-calorie diet, structured exercise program (unless medically contraindicated) and behavioral modification. The documentation must contain contemporaneous weights and physician medical record notes detailing the individual’s progress through the course of the program. A physician summary letter does not meet these documentation requirements
• In the year prior to surgery, the individual has participated in a multidisciplinary surgeon-supervised preparatory program for at least three consecutive months. Such a program must consist of dietary therapy (utilizing a dietician/nutritionist), a low-calorie diet, structured exercise program (unless medically contraindicated) and behavioral modification. The documentation must contain evidence of contemporaneous weights, physician oversight and physician medical record notes detailing the individual’s progress and completion of the program. A physician summary letter does not meet these documentation requirements
4. There must be evidence of a psychiatric or psychological evaluation demonstrating no barriers to the understanding of, and compliance with, the surgical procedure and required postoperative medical and dietary care. Individuals with active alcoholism, drug abuse or an uncontrolled major psychiatric disorder are not medically appropriate for bariatric surgery

Revision Requirements

A Repeat / Revision Surgery as long as all of the following criteria are met:

• The requested repeat bariatric surgery is covered according to the individual’s plan of medical benefits
• The individual met, or would have met, ConnectiCare’s medical necessity criteria for the previous bariatric surgery
• The repeat bariatric surgery is at least two years after the previous bariatric procedure
• A technical failure of the previous bariatric procedure has occurred and is documented in the physician office notes and diagnostic imaging reports (e.g., ultrasound, upper GI series, esophagogastroduodenoscopy)
• Following the previous bariatric surgery, the individual failed to lose at least 50% of his/her excess body weight or is more than 30% above ideal body weight
• Following the previous bariatric surgery, there is written documentation of full, consistent compliance with prescribed post-bariatric surgery care, including but not limited to, nutritional counseling, a structured exercise program, and behavioral support groups and/or psychological counseling. A physician summary letter does not meet this documentation requirement

ConnectiCare Contact Information and Full Medical Policy on Bariatric Surgery

• By Phone: (800) 251-7722
• Contact ConnectiCare
• Full Bariatric Surgery Medical Policy for ConnectiCare