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WELLCARE OF OHIO-HMO MEDICAID MEDICAL POLICY: WellCare considers Bariatric Surgery for the treatment of morbid obesity medically necessary when ALL the following criteria are met: Presence of morbid obesity has persisted for at least 5 years, defined as either: o BMI exceeding 40; or o BMI greater than 35 in conjunction with ANY of the following severe comorbid conditions: Coronary Heart Disease Type 2 Diabetes Mellitus Clinically significant Obstructive Sleep Apnea (i.e. patient meets the criteria for treatment of obstructive sleep apnea.) Medically Refractory Hypertension (blood pressure greater than 140 mmHg systolic and/or 90mmHg diastolic despite optimal medical management) Patient has completed growth (18 years of age or documentation of completion of bone growth). The member must participate in an organized multidisciplinary surgical preparatory regimen coordinated by a qualified bariatric surgeon of at least 3 months duration in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member’s ability to comply with postoperative medical care and dietary restrictions. Patient has participated in a physician-supervised nutrition and exercise program (including a low calorie diet, increased physical activity, and behavioral modifications). This physician-supervised nutrition and exercise program must meet ALL of the following criteria: o Participation in nutrition and exercise program must be supervised and monitored by a physician; AND o Nutrition and exercise program must be 6 months or longer in duration; AND o Nutrition and exercise program must occur with in the 2 years prior to surgery o Participation in physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who does not perform bariatric surgery. o Programs such as Weight Watchers, jenny Craig, OptiFast are acceptable alternatives if done in conjunction with physician supervision and detailed documentation of participation is available for review. However, physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement. Mental health evaluation by a psychiatrist or psychologist to determine any contraindications as listed below, mental competency and understanding of the nature, extent and possible complications of the surgery and ability to sustain dietary behavioral modifications needed to ensure a successful outcome of surgery. Contraindicated diagnoses are: o Active drug abuse o Active suicidal ideation o Borderline personality disorder o Schizophrenia o Psychotic disorder o Uncontrolled depression o Defined non-compliance with previous medical care REVISIONS: A complication of the original procedure, such as obstruction or stricture or failure of the primary procedure due to dilation of the gastric pouch (if the primary procedure was successful in inducing weight loss prior to the pouch dilation).