Common use of Gastric Restrictive Surgical Services Clause in Contracts

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- 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 six (36) 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 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. 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.may

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 35kgbetween 35.1-40 kg/m2 with significant co- 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 a Gastric Restrictive Surgical Services Service is required, including compliant attendance at a medically supervised weight loss program (within the last twenty-four (24) months) for at least three six (36) 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 SHL requires that an initial psychological/psychological/ psychiatric evaluation resulting in a recommendation for Gastric Restrictive Surgical Services is performed prior to review consideration by HPNSHL’s Managed Care Program. HPN SHL may also require participation in a post-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- 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 a Gastric Restrictive Surgical Services Service is required, including compliant attendance at a medically supervised weight loss program (within the last twenty-four (24) months) for at least three six (36) 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 SHL requires that an initial psychological/psychological/ psychiatric evaluation resulting in a recommendation for Gastric Restrictive Surgical Services is performed prior to review consideration by HPNSHL’s Managed Care Program. HPN SHL 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 a Gastric Restrictive Surgical Services Service 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 SHL requires that an initial psychological/psychological/ psychiatric evaluation resulting in a recommendation for Gastric Restrictive Surgical Services is performed prior to review consideration by HPNSHL’s Managed Care Program. HPN SHL 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.