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2011 FEP Coverage Guidelines for Morbid Obesity Surgery

Effective with the 2011 benefit period, prior approval will be required for outpatient surgery for morbid obesity. FEP members must meet specific pre-surgical criteria before receiving surgery for morbid obesity.

FEP 2011 Definition of Morbid Obesity:
A condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with co-morbidities who has failed conservative treatment; eligible members must be age 18 or over.

Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the following pre-surgical requirements.
The following requirements apply to gastric restrictive procedures, gastric malabsorptive procedures, and combination restrictive and malabsorptive procedures to treat morbid obesity:

  • Diagnosis of morbid obesity for a period of 2 years prior to surgery.
  • Participation in a medically supervised weight loss program, including nutritional counseling, for at least 3 months prior to the date of surgery.
  • Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating, and exercise.
  • Evidence that attempts at weight loss in the 1 year period prior to surgery have been ineffective.
  • Psychological assessment of the member's ability to understand and adhere to the pre- and post-operative program, performed by a psychiatrist, clinical psychologist, psychiatric social worker, or psychiatric nurse.
  • Patient has not smoked in the 6 months prior to surgery.
  • Patient has not been treated for substance abuse for 1 year prior to surgery.

Benefits for subsequent surgery for morbid obesity, performed on an inpatient or outpatient basis, are subject to the following additional pre-surgical requirements:

  • All criteria listed above for the initial procedure must be met again.
  • Previous surgery for morbid obesity was at least 2 years prior to repeat procedure.
  • Weight loss from the initial procedure was less than 50% of the member's excess body weight at the time of the initial procedure.
  • Member complied with previously prescribed postoperative nutrition and exercise program.
  • Claims for the surgical treatment of morbid obesity must include documentation from the patient's provider(s) that all pre-surgical requirements have been met.

REMINDER: Inpatient Admission Precertification for Federal Employees

Prior to admitting a Federal Employee into the hospital (*in a non-emergency situation), precertification must be obtained from the Service Benefit Plan.

To help members better understand their benefits and their potential costs and obligations to providers; please remind your Federal Employee-patients that precertification is required for all inpatient admissions. Based on the information provided, the request for an inpatient admission may be certified at an outpatient status by the plan rather than inpatient status which would result in higher out-of-pocket costs for the member.

We also ask that providers help keep members informed of precertification status and the Service Benefit Plan's approval or denial of an inpatient stay, so that members may better prepare and understand their portion of hospital-care costs.

*In the event of an emergency admission the Service Benefit Plan must be notified within two business days following the day of the emergency admission.