MY HMO Guideline I was denial
Guideline Age ≥ 18.3
2. Full growth achieved.
3. Absence of specific obesity etiology (i.e., endocrine disorders, e.g., adrenal or thyroid conditions, or treatment of metabolic cause provided, as applicable).
4. Absence of life-threatening condition that would not improve with surgery.
5. Active participation within the last 2 years in a physician-directed weight-management program for a minimum of
6 months without significant gaps. The weight-management program must include monthly documentation of all of the following components: Vital signs including weight. Current dietary program. Physical activity (i.e., exercise program). Behavioral interventions to reinforce healthy eating and exercise habits. Consideration of pharmacotherapy with U.S. Food and Drug Administration (FDA)-approved weight-loss drugs, if appropriate.4 2 Cholecystectomy may be performed as a preventative measure due to the substantially increased incidence of gallbladder disease subsequent to bariatric surgery. 3 Surgical requests for members < 18 years may be reviewed on a case-by-case basis and should only be performed in centers where there is a multidisciplinary approach to pediatric obesity and only in rare cir****tances (e.g., Prader-Willi syndrome). 4 Check member benefit for applicability. Bariatric Surgery Last review: January 19, 2011 Page 4 of 8 6. Psychological clearance by a mental health professional. If the member has received any behavioral health issue intervention (i.e., counseling or drug therapy) within the past 12 months, then the mental health provider should indicate that the issue of surgery has been discussed with the member and that there are no identified contraindications to the proposed surgery. In addition, the member should have no history of substance abuse, or if there is a positive history, the documentation should indicate that the member has been substance abuse free for >1 year or that he/she is in a controlled treatment program and is stabilized. Other contraindications include active eating disorders, active substance abuse and untreated psychiatric illness such as suicidal ideation, borderline personality disorder, schizophrenia, terminal illness and uncontrolled depression. AND BMI ≥ 40 kg/m² without comorbidities or BMI of 35-39.9 kg/m² with ≥ 1 significant comorbidity. Accompanying documentation of the following associated comorbid conditions and associated problems must be submitted; any of the following are applicable: Daily functional interference to the extent that performance is extensively curtailed.5 Documented circulatory insufficiency. Documented physical trauma secondary to obesity complications, which causes the member to be incapacitated. Documented respiratory insufficiency. Documented primary disease complication, as applicable: Coronary heart disease and other atherosclerotic diseases. Medically refractory hypertension. Osteoarthritis. Moderate to severe obstructive sleep apnea6 Type 2 diabetes.
2. Full growth achieved.
3. Absence of specific obesity etiology (i.e., endocrine disorders, e.g., adrenal or thyroid conditions, or treatment of metabolic cause provided, as applicable).
4. Absence of life-threatening condition that would not improve with surgery.
5. Active participation within the last 2 years in a physician-directed weight-management program for a minimum of
6 months without significant gaps. The weight-management program must include monthly documentation of all of the following components: Vital signs including weight. Current dietary program. Physical activity (i.e., exercise program). Behavioral interventions to reinforce healthy eating and exercise habits. Consideration of pharmacotherapy with U.S. Food and Drug Administration (FDA)-approved weight-loss drugs, if appropriate.4 2 Cholecystectomy may be performed as a preventative measure due to the substantially increased incidence of gallbladder disease subsequent to bariatric surgery. 3 Surgical requests for members < 18 years may be reviewed on a case-by-case basis and should only be performed in centers where there is a multidisciplinary approach to pediatric obesity and only in rare cir****tances (e.g., Prader-Willi syndrome). 4 Check member benefit for applicability. Bariatric Surgery Last review: January 19, 2011 Page 4 of 8 6. Psychological clearance by a mental health professional. If the member has received any behavioral health issue intervention (i.e., counseling or drug therapy) within the past 12 months, then the mental health provider should indicate that the issue of surgery has been discussed with the member and that there are no identified contraindications to the proposed surgery. In addition, the member should have no history of substance abuse, or if there is a positive history, the documentation should indicate that the member has been substance abuse free for >1 year or that he/she is in a controlled treatment program and is stabilized. Other contraindications include active eating disorders, active substance abuse and untreated psychiatric illness such as suicidal ideation, borderline personality disorder, schizophrenia, terminal illness and uncontrolled depression. AND BMI ≥ 40 kg/m² without comorbidities or BMI of 35-39.9 kg/m² with ≥ 1 significant comorbidity. Accompanying documentation of the following associated comorbid conditions and associated problems must be submitted; any of the following are applicable: Daily functional interference to the extent that performance is extensively curtailed.5 Documented circulatory insufficiency. Documented physical trauma secondary to obesity complications, which causes the member to be incapacitated. Documented respiratory insufficiency. Documented primary disease complication, as applicable: Coronary heart disease and other atherosclerotic diseases. Medically refractory hypertension. Osteoarthritis. Moderate to severe obstructive sleep apnea6 Type 2 diabetes.
Thanks for posting this peeches35, I myself am HMO and was wondering if I'd be approved. I am Type 2 diabetic so it seems I fit the criteria to be approved. I pray you win your appeal if you decide to or find other insurance...God bless! keep me in your prayers; i'll do the same for you. 
I can do all things through Christ Jesus, who strengthens me! 
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