BARIATRIC SURGERY - Health Plan of Nevada

epaired. An initial psychological/psychiatric evaluation that results in a recommendation for a Gastric
Restrictive Surgical Service is required prior to review. The health plan may also require participation
in a post-operative group therapy program.
Exclusions for the Following Products (Health Plan of Nevada Generic, Health Plan of Nevada
Premium and Health Plan of Nevada Open Access, Health Plan of Nevada Stations, UHC
Nevada Market, Clark County Employees). Except as provided in the Covered Services Gastric
Restrictive Surgical Services section, weight reduction services are excluded. Also excluded are any
weight loss programs, whether or not recommended, provided or prescribed by a Physician or other
medical practitioner.
Exclusions for the Following Products (Health Plan of Nevada Small Group, Catholic Charities,
Trust Plan 2). Surgical or invasive treatment (including gastric balloon) or reversal for reduction of
weight regardless of associated medical or psychological conditions, unless determined to be
Medically Necessary. Any weight loss programs, whether or not recommended, provided or prescribed
by a physician or other medical practitioner.
The National Heart, Lung and Blood Institute (NHLBI) classify the ranges of BMI in adults as
follows (NHLBI, 1998):
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