Gastric Restrictive Surgical Services Sample Clauses

Gastric Restrictive Surgical Services. Covered Services include Prior Authorized Medically Necessary Gastric Restrictive Surgical Services for extreme obesity under the following circumstances:  Have a body mass index (BMI) of greater than or equal to 40kg/m2; or  Have a BMI between 35.1-39.9 kg/m2 with significant co-morbidities; and  Can provide documented evidence that dietary attempts at weight control are ineffective; and  Must be at least 18 years old. Documentation supporting the reasonableness and necessity of Gastric Restrictive Surgical Services is required, including compliant attendance at a medically supervised weight loss program (within the last twenty-four (24) months) for at least six (6) consecutive months with documented failure of weight loss. Significant clinical evidence that weight is affecting overall health and is a threat to life will also be required. HPN requires that an initial psychological/psychiatric evaluation, resulting in a recommendation for Gastric Restrictive Surgical Services, be performed prior to review consideration by HPN’s Managed Care Program. HPN may also require participation in a post-operative group therapy program. Treatment for complications resulting from Gastric Restrictive Surgical Services will be covered the same as any other illness.

Gastric Restrictive Surgical Services. Covered Services include Prior Authorized Medically Necessary Gastric Restrictive Surgical Services for extreme obesity under the following circumstances: • Have a body mass index (BMI) of greater than 40kg/m2; or • Have a BMI greater than 35kg/m2 with significant co- morbidities; and • Can provide documented evidence that dietary attempts at weight control are ineffective; and • Must be at least 18 years old. Documentation supporting the reasonableness and necessity of Gastric Restrictive Surgical Services is required, including compliant attendance at a medically supervised weight loss program (within the last twenty-four (24) months) for at least three (3) months with documented failure of weight loss. Significant clinical evidence that weight is affecting overall health and is a threat to life will also be required. HPN requires that an initial psychological/psychiatric evaluation resulting in a recommendation for Gastric Restrictive Surgical Services is performed prior to review consideration by HPN’s Managed Care Program. HPN may also require participation in a post-operative group therapy program. Treatment for complications resulting from Gastric Restrictive Surgical Services will be covered the same as any other illness.

Gastric Restrictive Surgical Services. Covered Services include Prior Authorized Medically Necessary Gastric Restrictive Surgical Services for extreme obesity under the following circumstances:  Have a body mass index (BMI) of greater than 40kg/m2; or  Have a BMI greater than 35kg/m2 with significant co- morbidities; and  Can provide documented evidence that dietary attempts at weight control are ineffective; and  Must be at least 18 years old. Documentation supporting the reasonableness and necessity of Gastric Restrictive Surgical Services is required, including compliant attendance at a medically supervised weight loss program (within the last twenty- four (24) months) for at least three (3) months with documented failure of weight loss. Significant clinical evidence that weight is affecting overall health and is a threat to life will also be required.

Gastric Restrictive Surgical Services. Benefits for Mastectomy Reconstructive Surgery performed within three (3) years following a mastectomy that was covered under this Plan, while the patient is no longer covered by SHL under this Plan, will be paid at the same level as would have been provided at the time of the mastectomy except that no coverage will be provided for any complications relating to the Mastectomy Reconstructive Surgery. Benefits for Mastectomy Reconstructive Surgery performed more than three (3) years following a mastectomy that was covered under this Plan (if the patient is still covered by SHL under this Plan) will be paid subject to all of the terms, conditions and exclusions contained in the AOC at the time of the Mastectomy Reconstructive Surgery. No benefits will be paid for Mastectomy Reconstructive Surgery performed, or any complications relating to the Mastectomy Reconstructive Surgery, more than three (3) years following a mastectomy that was covered under this Plan if the patient is no longer covered by SHL under this Plan.

Gastric Restrictive Surgical Services. Covered Services include Prior Authorized Medically Necessary Gastric Restrictive Surgical Services for extreme obesity under the following circumstances: • Have a body mass index (BMI) of greater than 40kg/m2; or Form No. HPN-Ind_AOC(2015) Page 11