Excellus BCBS Weight Loss Surgery – How to Avoid a Denial

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

1. Be age 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
• Hypertensive cardiovascular disease
• Coronary heart disease
• Pulmonary hypoventilation
• Hypertension,
• Hypercholesterolemia
• Dyslipidemias
• Diabetes
• Sleep apnea
• Degenerative arthritis of weight-bearing joints or other weight related arthropathies
• Metabolic syndrome

Use this BMI Calculator to check your body mass index…

3. The condition of morbid obesity must be of at least 5 years duration
4. A letter of support from the physician currently providing primary care to the member and who is familiar with his/her attempts at weight reduction, medical history and current health status (including obesity issues) is also necessary for the review process
5. History of rigorous attempts at weight reduction:
• There must be written evidence of a weight loss history, either by the bariatric surgeon, primary care physician or nutritionist. This documentation should include the name of the weight loss program, length of participation in the program and any weight loss achieved. At least one program must have been a supervised weight loss program
• Weight loss attempts need not be continuous, but a minimum total of six months is required
• If the patient has had no previous attempts at medical weight loss, participation for a minimum of six months in a preoperative bariatric surgery weight loss program is required
• If past prior attempts of weight loss are remote (greater than 5 years), then the patient is required to participate, for a minimum of six months in a preoperative bariatric surgery weight loss programd
6. There must be no significant liver, kidney, or gastrointestinal disease present. The presence of non-alcoholic steatohepatitis or “fatty liver”, which is associated with morbidly obese patients, would not be considered significant liver disease in this instance
7. Treatable metabolic causes for obesity (e.g., adrenal or thyroid disorders) have been addressed
8. Patients with a history of alcohol or substance abuse will not be considered unless there is a record of at least six months of abstinence. If there has been six months of abstinence, this condition must be addressed in a psychiatric consultation
9. Patients must be screened by their physician for major psychopathology

Laparoscopic Adjustable Gastric Banding

Based upon our criteria and assessment of peer-reviewed literature, the surgical management of morbid obesity by laparoscopic adjustable gastric banding is considered medically appropriate in the following circumstances:

• The patient must meet all the requirements listed above in Policy Statement I, A-H
• The dietary history does not include a large consumption of high caloric liquids (e.g., milk shakes) or sweets
• The patient has no significant history of esophageal or gastric disease (please note contraindications to adjustable gastric banding listed in the rationale section)
• The patient must participate in a pre-operative bariatric program that requires a 5% weight loss to demonstrate commitment to behavioral and dietary changes. The 5% weight loss will be measured from the date of the patient’s initial visit to the bariatric surgeon to the date of the request for pre-authorization of the adjustable gastric banding procedure

Revision Requirements

A revision or removal of a laparoscopic adjustable gastric band is considered medically necessary for complications or for a technical failure. Examples of complications and technical failures that may warrant a revision, removal, or conversion to another procedure include:

• Band slippage
• Band erosion
• Infection
• Esophageal dilation
• Dysphagia
• Heartburn/reflux
• Displaced band
• Port dislocation
• Too tight a band creating food passage problems
• Band intolerance (e.g., pain, vomiting)
• Port and/or catheter leakage

A revision or conversion to another medically appropriate procedure because of unsatisfactory weight loss due to technical failure of the primary bariatric procedure such as pouch dilation or an initial pouch size that is too large is considered medically appropriate if there is documentation regarding all of the following submitted with the request:

• Primary procedure was initially successful in inducing weight loss
• Patient has remained compliant to the prescribed nutrition and exercise program

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

• By Phone: 1-877-883-9577
• Contact Excellus Blue Cross Blue Shield
• Full Bariatric Surgery Medical Policy for Excellus Blue Cross Blue Shield