BARIATRIC SURGERY - Health Plan of Nevada

WOU001
FEDERAL EMPLOYEE HEALTH BENEFIT PLAN COVERAGE RATIONALE
Gastric bypass (Roux-en-Y; gastrojejunal anastomosis), vertical banded gastroplasty (gastric
banding; gastric stapling), adjustable gastric banding (laparoscopic adjustable silicone gastric
banding), biliopancreatic bypass (Scopinaro procedure), biliopancreatic diversion with duodenal switch,
and laparoscopic bariatric surgery are medically necessary in adults for the treatment of clinically severe
obesity as defined by the National Heart Lung and Blood Institute (NHLBI) who have:
A. A body mass index (BMI) of greater than 40 kg/m2; or
B. A body mass greater than 35kg/m2 and significant co-morbidities such as;
1. cardiac disease; and/or
2. diabetes; and/or
3. hypertension; and/or
4. diseases of the endocrine system, e.g., Cushing's syndrome, hypothyroidism; and/or
5. disorders of the pituitary glands
6. disorders of the adrenal glands
Patient History:
1. Compliant attendance at a medically supervised weight loss program (within the last
24 months) for at least 3 months; and
2. Individuals must be age 18 or over; and
3. Have a psychological/psychiatric evaluation by a licensed practitioner, with a
recommendation for gastric restrictive surgery
Documentation Requirements:
1. History and physical; and
2. Risk factors including family history; and
3. Pulmonary evaluation and sleep study, if indicated; and
4. Documentation of medically supervised weight-loss therapy (dietary, physical
activity, behavior therapy, pharmacotherapy, combined therapy or other medically
supervised therapy) at least 3-months in duration; and
5. Provision made for post-operative support management program.
Limitations of Coverage:
1. No limit to number of surgeries.
2. Tier 1 benefit only.
3. Coverage for complications is specific per plan.
4. Copays are specific per plan.
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