Bariatric Surgery—80%

Services and Supplies Must Be Preauthorized With the Medical Review Agency. Approved Procedures Must Be Performed At A Bariatric Surgery Center of Excellence.

Surgery for morbid obesity (Roux-en-Y gastric bypass or RYGB) or FDA-approved adjustable gastric banding is covered if:

• The patient meets the plan's medical criteria; and
• Services are preauthorized by the plan's medical review agency; and
• The patient agrees to bariatric specific case management; and
• Services are received at a Bariatric Surgery Center of Excellence.

There is an annual maximum benefit of $15,000. If expenses exceed the $15,000 annual maximum, this plan will not pay the additional costs. These services always require 20 percent coinsurance and these coinsurance expenses do not apply toward the $2,300 annual coinsurance maximum. Covered services include:

• Consultation with a physician, dietician or nutritionist to supervise a nutrition and exercise program. A maximum of four visits is allowed over the course of 12 months.
• Pre-operation laboratory and other testing ordered by your physician to confirm your health status for obesity surgery.
• Psychological evaluation.
• The surgeon's surgical fee.
• The surgical assistant's fee.
• The anesthesiologist's fee.
• The inpatient or outpatient facility fee.
• LAP band fills.
• Services related to repeat bariatric procedures (subject to criteria).
• Services for complications related to bariatric procedures that were covered by this plan, or if the plan's criteria would have been met at the time the original procedure was performed.

The following qualifying criteria must be met:

• Patient must be at least 18 years old.
• Patient must have longstanding obesity (five years or more) with a body mass index (BMI) of 40 or greater or a BMI of 35-40 with any of the following significant comorbidities:
  • Coronary heart disease.
  • Type 2 diabetes mellitus.
  • Clinically significant obstructive sleep apnea.
  • Hypertension.
• Patient has no endocrine (i.e., thyroid) cause of obesity.
• Patient has no uncontrolled psychological, drug or alcohol problems.
• Patient has participated in an organized multidisciplinary surgical preparatory regimen (including dietician consultation, low calorie diet, increased physical activity unless medically contraindicated, and behavioral modification) of at least three months duration; or the patient has participated in a physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity unless medically contraindicated, and behavioral modification) for a cumulative total of six months or longer in duration within two years prior to surgery, with participation in one program of at least three consecutive months.
• Patient has a history of failed medically supervised weight loss attempts.
• Patient has undergone a pre-operative psychological evaluation and clearance.
• Patient is able to demonstrate a clear understanding of surgical options, possible short-term and long-term risks and complications.
• Patient is dedicated to recommended life style change and long term follow up recommendations.

The plan has selected a medical review agency to review pre-surgical treatment plans to ensure that the patient meets the plan's medical criteria. The medical review agency will also provide coordination and facilitation of treatment plan components as necessary and follow outcomes for those patients who are approved for, and have undergone, a covered bariatric surgery (case management). The goal is to ensure that there is a long-term plan for post operative medical management and adherence to the medical treatment plan.

To initiate the preauthorization process, please contact a Customer Service Representative at the Trust Office.

Benefits are not provided for:

1. Charges for counseling except as provided under "Mental Health Care" on pages 60-62, education, self-help instruction or training, behavior modification, lifestyle counseling, nutritional or fitness guidance except as provided by the bariatric surgery multidisciplinary surgery team.
2. Weight loss treatment or services whether or not you have other medical conditions related to or caused by excess weight, except as provided under this benefit.
3. Routine cholecystectomy when performed in concert with elective bariatric procedures.
4. Charges, including complications from a covered surgery, that exceed the annual plan maximum of $15,000.
5. Charges for complications related to bariatric procedures that were not covered by this plan, or if the plan's criteria had not been met at the time the original procedure was performed.
6. The cost of a nutrition/exercise program; protein drinks or nutritional supplements.