Highmark Health Weight Loss Surgery – How to Avoid a Denial

In order to be approved by Highmark Health 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
• Hypertension
• Cardiovascular heart disease
• Dyslipidemia
• Diabetes mellitus type II
• Sleep apnea

Use this BMI Calculator to check your body mass index…

3. The patient has received non-surgical treatment (e.g., dietitian/nutritionist consultation, low calorie diet, exercise program, and behavior modification) and attempts at weight loss have failed.
4. The patient must participate in and meet the criteria of a structured nutrition and exercise program. This includes dietitian/nutritionist consultation, low calorie diet, increased physical activity, behavioral modification, and/or pharmacologic therapy, documented in the medical record. This structured nutrition and exercise program must meet ALL of the following criteria:
• The nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists
• The nutrition and exercise program(s) must total six visits or more during a period of six consecutive months
• The nutritional and exercise program must occur within two years prior to the surgery
• The patient’s participation in a structured nutrition and exercise program must be documented in the medical record by an attending physician who supervised the patient’s progress. A physician’s summary letter is not sufficient documentation. Documentation should include medical records of the physician’s on-going assessments of the patient’s progress throughout the course of the nutrition and exercise program. For patients who participate in a structured nutrition and exercise program, medical records documenting the patient’s participation and progress must be available for review
5. The patient must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. The patient’s medical record documentation should indicate that all psychosocial issues have been identified and addressed.
6. Patient selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The member’s understanding of the procedure, and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure.

Adolecents Requirements

The eligible bariatric surgical procedures listed above unless otherwise specified are covered for members under the age of 18 years when they meet all of the following patient selection criteria:

1. Attainment or near-attainment of physiologic/skeletal maturity at approximately, age 13 in girls and 15 for boys. (The patient has attained Tanner 4 pubertal development and final or near-final adult height (e.g., ≥ 95 %) of adult stature).
2. The patient is morbidly obese defined as a BMI of 50+ or severely obese defined as a BMI 40+ with serious comorbidities:
• Severe obstructive sleep apnea
• Pickwickian syndrome
• Obesity related cardiomyopathy
• Pulmonary hypertension
• Dltwocumented coronary artery disease
• Pseudotumor cerebri
• Type II Diabetes
3. The patient has received non-surgical treatment (e.g., dietitian/nutritionist consultation, low calorie diet, exercise program, and behavior modification) and attempts at weight loss have failed.
4. The patient must participate in and meet the criteria of a structured nutrition and exercise program. This includes dietitian/nutritionist consultation, low calorie diet, increased physical activity, behavioral modification, and/or pharmacologic therapy, documented in the medical record. This structured nutrition and exercise program must meet ALL of the following criteria:
• The nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists
• The nutrition and exercise program(s) must total six visits or more during a period of six consecutive months
• The nutritional and exercise program must occur within two years prior to the surgery
• The patient’s participation in a structured nutrition and exercise program must be documented in the medical record by an attending physician who supervised the patient’s progress. A physician’s summary letter is not sufficient documentation. Documentation should include medical records of the physician’s on-going assessments of the patient’s progress throughout the course of the nutrition and exercise program. For patients who participate in a structured nutrition and exercise program, medical records documenting the patient’s participation and progress must be available for review
5. The patient must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. The patient’s medical record documentation should indicate that all psychosocial issues have been identified and addressed.
6. The patient must be able to show decisional capacity and maturity in the psychological evaluation and provide informed assent for surgical management.
7. The patient must be capable and willing to adhere to nutritional guidelines postoperatively.
8. The patient must have a supportive and committed family environment.
9. Patient selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The member’s understanding of the procedure and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure.

Revision Requirements

Surgical repair following gastric bypass and gastric restrictive procedure may be considered medically necessary when there is documentation of a surgical complication related to the original surgery, such as a:

• Fistula
• Obstruction
• Erosion
• Disruption/leakage of a suture/staple line
• Bad herniation
• Pouch enlargement with vomiting

Repeat surgical procedures for revision or conversion to another surgical procedure (that also may be considered medically necessary within this document) for inadequate weight loss, (that is, unrelated to a surgical complication of a prior procedure) may be considered medically necessary when all the following criteria are met:

• The individual continues to meet all the medical necessity criteria for bariatric surgery
• There is documentation of compliance with the previously prescribed postoperative dietary and exercise program
• Two years following the original surgery, weight loss is less than 50% of pre-operative excess body weight and weight remains at least 30% over ideal body weight (taken from standard tables for adult weight ranges based on height, body frame, gender and age, an example is available from the National Heart Lung and Blood Institute [NHLBI]

Revision of a sleeve gastrectomy is medically necessary for the following:

• Intractable GERD or reflux may require revision of a sleeve into a gastric bypass, by dividing the sleeve proximally, then constructing a Roux limb, then a gastrojejunostomy
• Persistent narrowing or stricture at a portion of the sleeve may make resection of that segment necessary or revision into a gastric bypass
• A chronic leak may mandate resection or revision
• Inadequate weight loss, or weight regain due to dilation of the sleeve
• Revision to a gastric bypass or to a duodenal switch for inadequate weight loss

Highmark Health Contact Information and Full Medical Policy on Bariatric Surgery

• By Phone: (412) 544-7000
• Contact Highmark Health
• Full Bariatric Surgery Medical Policy for Highmark Health