Common use of Bariatric Surgery Clause in Contracts

Bariatric Surgery. This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Biomarker testing is for the purposes of diagnosis, treatment, appropriate management or ongoing monitoring of a member’s disease or condition is covered if the test is supported by medical and scientific evidence such as FDA approval, CMS national or local coverage determinations, or nationally recognized clinical practice guidelines. Biomarker testing may be subject to cost sharing consistent with that imposed on testing benefits.