Common use of Gastric Banding and Bariatric Surgery Clause in Contracts

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

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-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

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

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-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