But the criteria first listed says that the following two criteria must be met for bariatric surgery, which I meet.
PATIENT SELECTION CRITERIA FOR COVERAGE
For a member to be considered eligible for benefit coverage of bariatric surgery to treat morbid obesity, the member must meet the following two criteria:
1. Diagnosis of morbid obesity, defined as a:
• Body mass index (BMI) equal to or greater than 40 kg/meter² (* see guidelines below for BMI calculation); OR
• BMI equal to or greater than 35kg/meters² with at least one (1) of the following clinically significant obesity-related diseases or complications that are not controlled by best practice medical management:
o Hypertension, OR
o Dyslipidemia, OR
o Diabetes mellitus, OR
o Coronary heart disease, OR
o Sleep apnea, OR
o Osteoarthritis; AND
2. Documentation from the requesting surgical program that:
• Growth is completed (generally, growth is considered completed by 18 years of age); AND
• Documentation from the surgeon attesting that the patient has been educated in and understands the post-operative regimen, which should include ALL of the following components:
1. Nutrition program, which may include a very low calorie diet or a recognized
commercial diet-based weight loss program; AND
2. Behavior modification or behavioral health interventions; AND
3. Counseling and instruction on exercise and increased physical activity; AND
4. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health; AND
• Patient has completed an evaluation by a master’s level or higher behavioral healthcare provider acting within the scope of their licensure under applicable state law, within the 12 months preceding the request for surgery. This evaluation should document:
1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations, AND
2. The absence of any psychological comorbidity that could contribute to weight mismanagement or a diagnosed eating disorder, AND
3. The patient’s willingness to comply with preoperative and postoperative treatment plans.