HealthChoice covers specific bariatric surgical procedures subject to certification and clinical criteria and guidelines set forth by the Certification Administrator. These procedures must be obtained from a Metabolic Bariatric Surgery Accreditation and Quality Improvement Program (MBSA-QIP) Comprehensive Center of Excellence contracted with HealthChoice as a network facility provider.
The benefit also includes related pre-operative and workup services. All covered procedures and related services are subject to plan provisions including member liability for copay, coinsurance and deductible amounts. The covered procedures 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 according to one of the following:
- As part of the HealthChoice bariatric surgery pilot program, dates of service Jan. 1, 2013, thru Dec. 31, 2017.
- Under the HealthChoice plans on or after Jan. 1, 2017.
The bundled allowed amount includes the facility, surgeon, assistant surgeon, anesthesiology, laboratory, pathology, radiology and other related services when those services are rendered on the same date or during the hospital confinement. These services are 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 or older, with no other primary coverage.
- The participant must be covered under a 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 health coverage with HealthChoice for 24 months post-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 not covered:
- Band and band revisions.
- Bariatric surgical services obtained from any facility that is not a HealthChoice bariatric network provider.
- Revisions to bariatric surgical procedures originally obtained during a time when the individual was not covered by HealthChoice.
- Revisions to bariatric surgical procedures originally obtained from a facility that was not a HealthChoice bariatric network provider.
- Related workup and postoperative services billed with a diagnosis code of obesity (ICD-10 code E66).