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Common Insurance Requirements for Surgical Treatment for Morbid Obesity

NOTE: WE ACCEPT MANY MORE INSURANCE PLANS THAN ARE LISTED BELOW, THESE ARE COMPANIES THAT HAVE SPECIFIC REQUIREMENTS THAT WILL NEED TO BE MET FOR APPROVAL OF WEIGHT LOSS SURGERY. PLEASE CALL US IF YOU HAVE QUESTIONS ABOUT YOUR INSURANCE PLAN, AS REQUIREMENTS MAY VARY PER POLICY.

Universal Treatment Requirements

NIH criteria for surgical treatment of obesity:
(BMI = Body Mass Index: wt (kg)/ht(m)sq.)
BMI > 40 (80-100lbs overweight)
BMI > 35 with presence of severe co-morbid conditions such as diabetes, GERD, hypertension, heart disease or sleep apnea

If you are below a 35 BMI, you are not a candidate for weight loss surgery.

United Healthcare (all plans)

Subject only to plan limitations and universal treatment requirements established by the individual employer.

Aetna US Healthcare (all plans)

  • Two year documented (in patient record) history of morbid obesity
  • Psychiatric evaluation (if indicated with medical history)
  • Three month supervised pre-surgery diet and exercise regimen

CIGNA (all plans)

  • Legible documentation from physician supervising at least a 3 month diet (Weight Watchers, Jenny Craig and Optifast type programs are acceptable as long as they are in conjunction with physician supervision and documentation is available for review) within the past 12 months. NOTE: A physician’s summary letter is not sufficient documentation – the records must be in the patient’s chart notes.
  • Medical evaluation and recommendation for surgery by PCP
  • Psychiatric evaluation
  • Nutrition evaluation with a registered dietitian
  • Care plan for long-term follow-up. (Provided by surgeon)

Great West (all plans)

  • Legible documentation from physician supervising at least a 6 month diet
  • Five year documented (in patient record) history of morbid obesity
  • Psychiatric evaluation
  • Dietitian consultation and evaluation
  • Documentation of previous weight loss attempts
  • Documentation of a 12 week, physician-supervised weight loss attempt, having taken place within the previous 12 months

NOTE: GREAT WEST WILL NOT COVER ADJUSTABLE GASTRIC BANDS IF BMI > 50

Blue Cross/ Blue Shield

  • Requirements vary per plan, per state of plan administration.
  • We are currently only able to see PPO and POS plan holders. We are out of network for all others.

Medicare

WE ARE NOW ACCEPTING NEW MEDICARE PATIENTS.

Pacificare (all plans)

WE ARE NO LONGER ACCEPTING NEW PACIFICARE PATIENTS.
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