• TennCare – Requirements for Weight Loss Surgery Approval

    Posted By on Oct 19, 2013 | 0 comments


    To qualify for coverage of weight loss surgery, your policy must include coverage. Not all policies include coverage. To find out if you policy includes coverage, please talk directly to TennCare.

    TennCare does cover weight loss surgery for those individuals that meet certain criteria. In 2011 TennCare adopted the guidelines that Blue Cross Blue Shield uses for bariatric surgery.

    TennCare’s pre-approval requirements

    For TennCare to cover your weight loss surgery the following are required:

    1. A body mass index of 40 or greater.
    2. OR a body mass index of 35 and greater with at least 2 comorbidities that may include:
      • Diabetes
      • Hypertension
      • High Cholesterol (hyperlipidemia)
      • Sleep Apnea
    3. A documented history of being morbidly obese for at least 5 years.
      • This is usually obtained from doctors visits such as your annual physical exam.
    4. Participation in a medically supervised weight loss program. This must be documented and it should have occurred within the last two years prior to surgery.
    5. A letter recommending weight loss surgery from your primary care physician.
    6. Psychological evaluation.

    Patient’s that are part of TennCare AmeriGroup may also require blood work, clearance from a cardiologist and/or pulmonologist and a nutritional evaluation.

    Types of weight loss surgeries covered by TennCare

    • Gastric Bypass
    • Lap Gastric Bands
    • Gastric Sleeves
    • Duodenal Switch Surgery

    Are lap band fills covered?

    Yes. Lap gastric band fills are covered as necessary to maintain weight loss after your procedure.

    What procedures are excluded from coverage?

    Procedures outside of the covered list are considered experimental and therefore not covered by TennCare. Which procedure is right for you?

    Do I have to use an in-network Bariatric Surgeon?

    For revisions you will need to use a TennCare approved surgeon.

    TennCare contact information to inquire about surgery

    TennCare can be contacted on the TennCare website.

    They can also be reached by phone at: 1-800-565-9140

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