HealthChoice covers specific bariatric surgical procedures subject to certification and clinical criteria and guidelines set forth by the Certification Administrator. Bariatric surgical procedures must be obtained from a Metabolic Bariatric Surgery Accreditation and Quality Improvement Program (MBSA-QIP) Comprehensive Center of Excellence who is contracted with HealthChoice as a network facility provider.
The benefit includes the following services and all covered surgical procedures and related pre-operative and work-up services for the bariatric surgery services. The covered procedures available are:
- Duodenal Switch.
- Revision and conversions of a sleeve, bypass or duodenal switch procedure when medically necessary. The initial bariatric surgical procedure must have been performed:
- As part of the HealthChoice bariatric surgery pilot program, dates of service Jan. 1, 2013, thru Dec. 31, 2017, or under the HealthChoice plans on or after Jan. 1, 2017.
Revisions and conversions are subject to certification and plan provisions including member liability for copay, coinsurance and deductible amounts.
The bundled bariatric surgery allowed amount includes the following applicable services when rendered on the date of the outpatient service or during the inpatient stay; facility, surgeon, assistant surgeon, anesthesiology, laboratory, pathology, radiology and other related services as indicated with certification for the surgical procedure and is subject to bundled reimbursement methodology and plan provisions including member liability for copay, coinsurance and deductible amounts.
To be eligible for the benefit, participants must be a HealthChoice member, spouse or child, age 18 and older, with no other primary coverage.
- The participant must be covered under the HealthChoice Health Plan for 12 consecutive months prior to bariatric surgery regardless if the member has been eligible under other plans offered by EGID.
- The participant will be encouraged to continue coverage with the HealthChoice Health Plan for 24 months post bariatric surgery.
- The participant must meet specific criteria which includes, but is not limited to, severity of obesity, reliable participation in preoperative weight-loss program that is multidisciplinary, and expectation of adherence to postoperative care.
The following services are considered non-covered:
- Band and band revisions.
- Bariatric surgical services obtained from any facility that is not HealthChoice Bariatric Network provider.
- Revisions to bariatric surgical procedures obtained during a time when the individual was not covered by HealthChoice.
- Revisions to procedure that were originally obtained from a facility that was not a HealthChoice Bariatric Network provider when the original services were obtained.
- Related work-up and post-op services billed with a diagnosis code of obesity (ICD-10 code E66).