Health Net Weight Loss Surgery Requirements & Free Insurance Check. READ THIS FIRSTEven if your insurance company covers bariatric surgery in some plans, that does not mean that your specific plan covers it. The obesity surgery approval requirements in this section assume that weight loss surgery is covered by your specific policy. To confirm whether your specific policy covers bariatric surgery, click here to contact a surgeon and ask for a free insurance check. Disclaimer: The information contained on this page may not include all components of your insurance company’s medical policy and/or may not be up to date. Contact your insurance company to confirm all benefits. In order to be approved by Health Net for bariatric surgery in the United States, you must meet the following criteria: Patient is between 1. For at least 2 years or greater, the patient has clinically severe obesity (morbid obesity) defined by either of the following: Or. BMI between 3. 5 and 3. Severe, active coronary artery disease. Obesity- related cardiomyopathy. Congestive heart failure. Obstructive sleep apnea with use of CPAP or polysomnogram showing apnea- hypopnea index (AHI) of at least 1. Pickwickian syndrome. Type 2 diabetes mellitus. Clinically significant asthma. Chronic venous insufficiency with pain on weight bearing and persistent edema. Respiratory insufficiency, as evidenced by p. CO2 > 5. 0 mm. Hg, FEV1/FVC < 6. DLCO < 6. 0%Hypoxemia at rest, as evidenced by p. O2 < 5. 5 mm. Hg on room air. Do You Need Surgery For Weight Loss? Weight loss surgery helps people with extreme obesity to lose weight. It may be an option if you cannot lose weight through diet. Located in the beautiful Golden Isles of Southeast Georgia and specializing in weight loss surgery, Georgia Coast Surgical provides the excellent care you need to be. Severe gastroesophageal reflux disease (GERD)Severe pain and limitation of motion in any weight- bearing joint or the lumbosacral spine documented by physical examination in association with radiologic findings showing degenerative osteoarthritis. Patient has at least one of the following: Hypertension (blood pressure > 1. Hg systolic and/or > 9. Hg diastolic measured with appropriate size cuff) that has not responded to medical therapy. First degree relative with premature (age < 5. Hypercholesterolemia > 2. L that has not responded to medical therapy. Hypertriglyceridemia > 4. L that has not responded to medical therapy. Low density lipoprotein (LD) > 1. High density lipoprotein (HDL) < 3. Impaired fasting glucose > 1. Pulmonary hypertension. Patients with History of Alcohol / Hard- Core Substance Abuse. Patients with a history of alcohol or hard- core substance abuse should not be considered a candidate unless there is a record of at least one year of abstinence, which must be documented by random negative urine samples/blood alcohol levels/breathalyzer testing. If there has been a one- year abstinence, this condition must be addressed in a psychiatric consultation. Use this BMI Calculator to check your body mass index. Although patients undergoing bariatric procedures invariably have a history of failed dieting, preoperative weight loss can improve patient safety for these procedures. Aggressive medical therapies, such as very low calorie diets, are transiently effective for morbidly obese patients. The major limitation of medical obesity treatments for these patients is generally unsustainable weight loss rather than an inability to lose weight at all. Given these circumstances, preoperative weight loss can prove to be a reasonable approach to reduce adverse outcomes for superobese bariatric surgical patients but is not required prior to surgery. All patients must undergo a preliminary psychological evaluation by licensed mental health care professional (LCSW, MFCC, MSW Ph. D) familiar with the implications of weight reduction surgery. If pathology is identified, then an evaluation by a psychologist / psychiatrist is required and the member must receive clearance before surgery is performed. Adolescents Requirements. Cedar Park Bariatrics Specializing in Weight Loss Surgery. At Cedar Park Surgeons, PA, our skilled, compassionate surgeons Dr. Alan Abando and Dr. Nicole Basa turn. This NHS BMI calculator checks BMI (body mass index). Use it to calculate adult BMI and child BMI accurately, and get advice and information on healthy weight management. Many people who have lost 100 pounds or more are overjoyed at their success. After losing a lot of weight, though, you still may have loose, heavy folds of skin left. Weight loss surgery, also called bariatric or metabolic surgery, is sometimes used as a treatment for people who are very obese. It can lead to significant weight. BMISurgery - Bariatric Gastric Bypass Lap-Band Laparoscopy Surgery Vertical Sleeve Gastrectomy : - Vitamins & Minerals Protein Shakes bariatric, Formula RB, Formula. Health Net Weight Loss Surgery Requirements & Free Insurance Check. Your Health Net weight loss surgery insurance coverage depends on several factors, all of which. Leaders in Bariatric Weight Loss Surgery in Kansas City and the Nation. Patient is an adolescent between 1. Patient has made a reasonable effort to lose weight and chart notes must document that these attempts at dietary control have been ineffective in achieving a medically significant long- term weight loss. Attainment or near- attainment of physiologic maturity (Tanner stage V) – in some cases, a bone age may be required to determine skeletal maturity as evidenced by fused epiphyses. Health Net’s Tanner Stage V Definition. Tanner Stage V includes all of the following characteristics: Hair extends to medial surface of the thighs. No skeletal growth over last year. For male, testicular volume greater than 2. For female, breast reaches final adult size; areola returns to contour of the surrounding breast, with a projecting central papilla. Severe obesity defined as: A BMI of 4. Type 2 diabetes mellitus. Benign intracranial hypertension (Pseudotumor cerebri)Obstructive sleep apnea. Obesity hypoventilation syndrome. A BMI of 5. 0 or above with less severe comorbiditiesweight related arthropathieshypertensiondyslipidemiavenous stasis diseasepanniculitisurinary incontinencesignificant impairment in activity of daily livingnonalcoholic fatty liver disease (includes steatohepatitis)gastroesophageal refluxsevere psychosocial distress. Commitment to comprehensive medical and surgical evaluations before and after surgery. Avoidance of pregnancy for at least 1 year postoperatively. Capable and willing to adhere to lifelong follow- up with nutritional counseling and biochemical surveillance postoperatively. Must be able to show decisional capacity and emotional maturity in psychological evaluation and provide informed consent. Supportive and committed family environment. Surgery is considered investigational and therefore not medically necessary in an adolescent when any of the following is met: Presence of a medically correctable cause of obesity (e. An alcohol or substance abuse problem within the previous 1. A medical, psychiatric, or cognitive disability that impairs ability for adherence of postoperative diet. Current pregnancy or breastfeeding, including planned pregnancy within the first year after surgery. Inability or unwillingness of the patient or parents to understand the procedure and its medical consequences, including the need to maintain lifelong dietary requirements. Contraindications for Bariatric Surgery Procedures. Surgery may be denied by Health Net if the individual demonstrates one or more of the following: Non- compliance with previous medical care. Symptomatic coronary artery disease. End- stage renal disease (relative)Poor myocardial reserve (EF < 3. Significant chronic obstructive airways disease or respiratory dysfunction. Active peptic ulcer disease. Advanced cancer. When drug level maintenance is critical, such as: Patients with seizure disorders requiring anti- seizure medications. Patients with mental illness who require maintenance medication Bariatric Surgery. Adjustable gastric banding surgery is contraindicated in patients with gastroesophageal reflux pre- operatively, those who plan to stay on nonsteroidal anti- inflammatory drugs and other mucosal irritating drugs. Psychological disorder(s) of a significant degree that a psychologist / psychiatrist thinks it would be exacerbated by or interfere with the long term management of the patient after the operation, such as: Active substance and alcohol abuse. Significant eating disorders. Untreated schizophrenia. Uncontrolled major depression. BMI Calculator for Bariatric Surgery. Body Mass Index (BMI) is a number calculated from a person’s weight and height and is used as part of the Bariatric Surgery.Manic- depressive disorder. Psychotic disorders. Borderline personality disorder. Mental retardation. Psychological criteria to exclude patients from consideration for surgery: Active psychosis present (defined as current evidence of active psychosis and/or mental health hospitalization for psychosis within past 1 year)History of multiple (3 or more) suicide attempts within the past 5 years. Alcohol use disorder within past 6 months. Other substance use disorder within past 6 months (use of cannabis only might be an exception)Borderline personality disorder as indicated by medical record, clinical interview, or results of MMPIHistory of poor compliance with medical regimens appointment keeping, follow- up instructions or evidence on MBMDO or MMPIO that patient is very high risk for this. Delay consideration for surgery pending response to further psychological treatment: Poorly controlled mental illness(es) or cognitive impairment that may interfere with ability of patient to comply with necessary instructions and follow up (e. GI series), as well as: the individual experienced weight loss prior to the technical failurethe individual was compliant with the prescribed postoperative diet and exercise programs. Conversion to an alternative procedure if the member has inadequate weight loss which is defined as failure to lose at least 5. Body weight and BMI information is available from the National Heart Lung and Blood Institute . It’s all about how your doctor and hospital submit your claims to your insurance company. For example, there are many non- bariatric surgery reasons for your doctor to recommend: Cardiology exam. Lab work. Medically supervised diet program. Psychological exam. Sleep study. These are ordered for many reasons other than bariatric surgery and may be covered as a result. If your doctor submits one of these claims using a weight loss surgery CPT code (Current Procedural Terminology Code), your insurance is unlikely to cover it. After all, these tests will be beneficial regardless of whether you move forward with surgery.
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