MISCELLANEOUS PROCEDURE COVERAGE STATEMENTS
• Repeat/Revision of bariatric surgery: may be considered medically necessary (when specifically included as a benefit or covered service in the member’s benefit plan, summary plan description or contract) only whenALL of the following criteria are met:
o Original surgery was considered a covered benefit of the member’s current plan, AND the repeat/revision of bariatric surgery is a covered benefit of the member’s current plan; AND
o For the original procedure, patient met all the screening criteria, including BMI requirements; AND
o The patient has been compliant with a prescribed nutrition and exercise program following the original surgery; AND
o Significant complications or technical failure (e.g., break down of gastric pouch, slippage, breakage or erosion of gastric band, bowel obstruction, staple line failure, etc.) of the bariatric surgery has occurred that requires take down or revision of the original procedure that could only be addressed surgically; AND
o Patient is requesting reinstitution of an acceptable bariatric surgical modality.
• New bariatric surgery following a previous different bariatric procedure: A Roux-en-Y procedure following a previously approved vertical banded gastroplasty or laparoscopic adjustable banded gastroplasty is not eligible for coverage for patients who have been substantially noncompliant with a prescribed nutrition and exercise program following the original procedure.
But they encouaged me to come in and pay for all the pretesting anyway....
