Gastric Banding and Bariatric Surgery. Gastric banding and bariatric surgery will only be covered if such treatment is in accordance with the following: Company covers bariatric surgery using a covered procedure outlined below as medically necessary when ALL of the following criteria are met: o The individual is ≥ 18 years of age or has reached full expected skeletal growth AND has evidence of EITHER of the following: a BMI (Body Mass Index) ≥ 40 a BMI (Body Mass Index) 35-39.9 with at least one clinically significant comorbidity, including but not limited to, cardiovascular disease, Type 2 diabetes, hypertension, coronary artery disease, or pulmonary hypertension o Failure of medical management including evidence of active participation within the last two years in a weight-management program that is supervised either by a physician or a registered dietician for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of ALL of the following components: weight current dietary program physical activity (e.g., exercise program) Programs such as Weight Watchers®, Xxxxx Xxxxx® and Optifast® are acceptable alternatives if done in conjunction with the supervision of a physician or registered dietician and detailed documentation of participation is available for review. For individuals with long-standing, morbid obesity, participation in a program within the last five years is sufficient if reasonable attendance in the weight-management program over an extended period of time of at least six months can be demonstrated. However, physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement. o A thorough multidisciplinary evaluation within the previous 12 months which includes the following: an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s) and all of the associated current CPT codes a separate medical evaluation from a physician other than the surgeon recommending surgery, that includes a medical clearance for bariatric surgery unequivocal clearance for bariatric surgery by a mental health provider a nutritional evaluation by a physician or registered dietician
