Gastric Bypass Program

Gastric Bypass Surgery (GBS) is an expensive option to address excess weight and isn't suitable for everyone. The phases of the program, outlined below, are designed to maximize the success of GBS and prepare the member mentally and physically for a lifetime lifestyle change that will occur after the surgery. Gastric Bypass Surgery will be covered under the health plan if the member meets set criteria that has been established by the South Dakota State Employee Health Plan and Health Care Medical Technology. The Gastric Bypass Program is set up and managed in 4 phases as outlined below: Phase I - Evaluation Phase Member must agree to provide HCMTI with the following: a recommendation of surgery from his/her primary care physician along with an exercise routine and duration recommendation. A Surgical, Nutritional and Psychological Evaluation After HCMTI has received the above mentioned documents, our Medical Director will make a recommendation as to whether the member needs to participate in 12 months of the Gastric Bypass Program (phase II) or proceed directly to surgery (phase III). Phase II - Participation in the Gastric Bypass Program for a period of 12 months prior to surgery During this 12 months members must submit weekly information to HCMTI as outlined below: 90 minutes of combined exercise/week or as recommended by member's primary care physician. This information should include duration and type of exercise performed. 4 food diaries/week 4 behavior modification summaries member must also submit an accurate monthly weight to HCMTI. Compliance is measured by completion of the above and sustained weight loss during Phase II of the program. Weight gain based off of Surgical Evaluation weight will be considered non-compliant and the member then becomes ineligible for surgery. The Medical Director may renew participation at the end of the 12 month period. Phase III - Gastric Bypass Surgery approval and completion Phase IV Mandatory- Participation in the Gastric Bypass Program for a period of 12 months prior to panniculectomy surgery During this 12 months members must submit weekly information to HCMTI as outlined below: 90 minutes of combined exercise/week or as recommended by member's primary care physician. This information should include duration and type of exercise performed. 4 food diaries/week 4 behavior modification summaries member must also submit an accurate monthly weight to HCMTI. Compliance is measured by completion of the above and once member reaches ideal body weight they would be eligible for Panniculectomy Surgery. Guidelines to determine eligibility for Gastric Bypass Surgery are as follows: The member must have a Body Mass Index of 40 or greater, with at least 2 co-morbid conditions directly related to obesity or a BMI of 55 or greater with or without co-morbid conditions. (The HCMTI Medical Director will determine clinical significance of the co-morbidities.) The member must have failed multiple attempts at weight loss through physician-approved programs with or without pharmacotherapy. Phase I must be completed before member can advance to Phase II of the GBS Program. Successful participation in the Weight Management Program or the Weight Management portion of the Metabolic Syndrome Program may count toward the required 12 month participation in the Gastric Bypass Program. The member must agree to enter the plan's health management program for 12 months before and 12 months after surgery. The member must agree to join a weight loss program, approved by his or her doctor and the health plan, which will provide nutrition, exercise and behavioral modification for the two-year time period described above. Participation will be monitored by the health plan and the plan's Health Management Team. Member must agree to provide documentation of participation. The plan limits one gastric bypass/laparoscopic surgery per lifetime regardless of source. The appropriateness of the type of surgery will be evaluated by the Medical Director. To learn more about the Gastric Bypass Program, please contact the weight health manager at 877-977-0159. Click here for the weight management fact library!