Bariatric Surgery Benefit for Treatment of Morbid Obesity Sample Clauses

Bariatric Surgery Benefit for Treatment of Morbid Obesity. Shared costs apply for some of these services, as described in Part XII of this Certificate. The benefit of morbid obesity treatment requires a waiting period of twelve (12) months from the time of effectiveness of the certificate, unless a physician certifies that the life of the person is in imminent risk. Covered services include: gastric bypass surgery, adjustable band surgery or sleeve gastrectomy (open or closed procedures through laparoscopy). Other methods of bariatric surgery are excluded from this certificate. The insured is responsible for the applicable coinsurance and for copayment for hospital admission. Coverage is subject to pre-authorization of the procedure from MCS Life Clinical Affairs, and the procedure will be covered through providers contracted by MCS Life in Puerto Rico. Bariatric surgery is limited to one (1) procedure for life. To begin the authorization procedure, the insured must meet the minimum requirements described below: Body Mass Index (BMI) greater than or equal to thirty-five (35) Diet treatment regime during at least six (6) months, supervised by a physician or bariatric surgeon prior to the surgery. In addition, the physician should indicate the diet regime used and reason for failure. cardiovascular or cardiopulmonary diseases, severe diabetes, arthritis and sleep apnea, in accordance with Article 3(c) of Law No. 212 of August 9, 2008. Assessment by a mental health specialist (psychologist or psychiatrist) certifying that the insured understands and is willing to follow life style changes required for a successful bariatric procedure. Surgeries for removing excessive skin (commonly known as flaps) are not covered, except if the physician certifies the need to remove excessive skin as it affects the functioning of a body part.
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