Co-Morbidity

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CO-MORBIDITIES
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UPDATE AS OF 2007: This entry was written in Dec 2003. The co-morbidities requirements from medical insurance companies of today that are covered has since been revised and changed. As of April 2006, the co-morbidities that must be present with a person diagnosed with morbidi obesity has to include ONE of the following:

* sleep apnea
* diabetes
* hypertension

Always check with your medical insurance company for their critieria and requirements regarding bariatric surgery and which procedure they do cover.

Below was written in my OH journal in 2003

There are 6 medical related fatal co-morbidities that are view of extreme importance when it comes to morbid obesity. The MAJORITY of medical insurance companies only authenticate these primary diagnosis as medical necessity since morbid obesity (code 278.01) alone WILL NOT grant you approval for gastric bypass surgery. Listed are the 13 co-morbidities used by medical insurance companies and deemed medically necessary for bariatric surgical approval.

Many insurance companies require a minimum of 2 co-morbids associated with a BMI=40+. Some insurance companies will approve surgery if 1 co-morbidity has been diagnosed. In addition, I gave an explanation what each are for those not aware what exactly it means and also help if you may have any of these symptoms..

Treatment of obesity alone is non-covered by medical insurance companies, so co-morbidity must be documented, such as ONE or MORE of the following;

* diabetes

* Pickwickian Syndrome or sleep apnea

* hypertension

* cardiac disease

* severe venous stasis disease

* osteoarthritis aggravated by the obesity


There must be evidence, in addition, that the beneficiary has failed multiple efforts at dietary control of the obesity. Documentation of all the forgoing must be submitted with the claim. In other words, a time frame is not always be needed regarding diet history, only that a couple of attempts to lose weight through dieting failed. Do check with your insurance compannies for exact interepretation to this matter.

Gastric bypass surgery, which is a variation of the gastrojejunostomy, is performed for patients with extreme (morbid) obesity. Gastric bypass surgery for extreme obesity is covered if

(1) it is medically appropriate for the individual to have such surgery;

(2) the surgery is to correct an illness which caused the obesity or was aggravated by the obesity.


Patient selection criteria for surgical treatment of morbid obesity should be in concert with the current community medical standards of practice

* BMI > 40

* presence of associated medical co-morbidities

* absence of psychological contraindications and

* patient history of failed medical weight loss


1.ASTHMA (code 493.00 - 193.92)
An inflammatory disorder of the airways that causes airflow into and out of the lungs to be restricted. It is characterized by periodic attacks of wheezing, shortness of breath, chest tightness and coughing

2. BRONCHIECTASIS (code 494.1)
When listening to the chest with a stethoscope, the doctor may hear small clicking, bubbling, rattling or other sounds, usually in the lower lobes of the lungs. It is often caused by recurrent inflammation or infection of the airways.

3. CARDIOMYOPATHIES (code 425.4 - 425.9)
Cardiomyopathy is a serious disease in which the heart muscle becomes inflamed and loses its ability to pump blood. The heart rhythm is disturbed, leading to irregular heartbeats known as arrhythmias. Cardiomyopathy can be classified as primary or secondary. The ventricles becomes excessively "rigid," so it's harder to fill with blood between heartbeats. A person often complains of being tired, may have swollen hands and feet and may have difficulty breathing on exertion. The condition tends to be progressive and sometimes worsens fairly quickly and is a leading reason for heart transplantation.

4. CHRONIC AIRWAY OBSTRUCTION (code 496)
A blockage of the upper airway, which can be in the trachea (windpipe), laryngeal (voice box) or pharyngeal (throat) areas.

5. CHRONIC PULMONARY HEART DISEASE (code 416.9)
High blood pressure in the blood vessels of the lungs in which leads to heart complications.

6. CORONARY ATHEROSCLEROSIS (code 414.00 - 428.9)
Caused by insufficient blood flow to the heart muscle. Symptoms include chest pain, shortness of breath, weakness, tiredness, reduced exertional capacity, dizziness, palpitations, leg swelling, weight gain. Physical examination may reveal the following findings: tachycardia, heart rate irregularity, high or low blood pressure, diaphoresis, tachypnea, syncope, leg edema, heart murmurs, pulmonary congestion.

7. DIABETES MELLITUS (code 250.00 - 250.93)
A life-long disease marked by elevated levels of sugar in the blood. It can be caused by too little insulin (a chemical produced by the pancreas to regulate blood sugar), resistance to insulin, or both. To understand diabetes, it is important to first understand the normal process of food metabolism. Several things happen when food is digested – a sugar called glucose enters the bloodstream. Glucose is a source of fuel for the body. An organ called the pancreas makes insulin. The role of insulin is to move glucose from the bloodstream into muscle, fat, and liver cells, where it can be used as fuel. People with diabetes have high blood glucose. This is because their pancreas does not make enough insulin or their muscle, fat, and liver cells do not respond to insulin normally or both.

8. EMPHYSEMA (code 492.0 - 492.8)
A lung disease which damages the air sacs (alveoli) in the lungs. The air sacs are unable to completely deflate and are therefore unable to fill with fresh air to ensure adequate oxygen supply to the body. Cigarette smoking is the most common cause of emphysema. Tobacco smoke and other pollutants are thought to cause the release of chemicals from within the lungs that damage the walls of the air sacs. This damage becomes worse over time, affecting the exchange of oxygen and carbon dioxide in the lungs.

9. ESOPHAGITIS (code 530.11 - 530.19)
An inflammation, irritation and swelling of the esophagus (the tube that leads from the back of the mouth to the stomach). It is caused by backflow of acid-containing fluid from the stomach to the esophagus (gastroesophageal reflux). It can also be caused by vomiting, surgery, medications or hernias. The infection or irritation can cause the tissues to become inflamed and can occasionally cause ulcers. There may also be difficulty when swallowing and a burning sensation in esophagus.

10. HYPERTENSION (code 401.0 - 405.19)
A disorder characterized by high blood pressure; generally this includes systolic blood pressure (the "top" number of your blood pressure measurement, which represents the pressure generated when the heart beats) that is consistently higher than 140 or diastolic blood pressure (the "bottom" number of your blood pressure measurement, which represents the pressure in the vessels when the heart is at rest) that is consistently over 90. Blood pressure is determined by the amount of blood pumped by the heart and the size and condition of the arteries. Many other factors can affect blood pressure, including volume of water in the body; salt content of the body; condition of the kidneys, nervous system or blood vessels; and levels of various hormones in the body.

11. HYPERTENSIVE HEART DISEASE (code 428.0 - 428.9, 405.01 - 405.99)
High blood pressure increases the workload of the heart, and over time, this can cause thickening of the heart muscle and the symptoms of hypertensive heart disease. As the heart continues to pump against elevated pressure in the blood vessels, the left ventricle becomes enlarged, cardiac output (the amount of blood pumped by the heart each minute) goes down, and without treatment, symptoms of congestive heart failure may develop. It is a late complication of hypertension (high blood pressure) that affects the heart.

12. OSTEOARTHROSIS (code 715.09 - 715.96)
A gradual and subtle onset of deep aching joint pain of either or combination of hands, fingers, hips, knees, big toe, cervical and lumbar spine causing deterioration of joint cartilage that includes pain on weight bearing bones, after exercising, pain during rainy weather, swelling, limited movement, morning stiffness and grating of joints with motion


RENAL DISEASE (403.00 - 403.91, 404.00 - 405.91)_
Any disorder of the kidneys (renal) or the kidney/urinary tract (urologic). For bariatric insurance surgical approval, renal/kidney problems alone is not approve as primary diagnosis related co-morbidity for morbid obesity. The renal condition is secondary and must be related to hypertension which would be the primary condition co-morbid for morbid obesity.

13. SLEEP APNEA (780.51 - 780.57)
Repeated, prolonged episodes of cessation of breathing during sleep. In deep sleep, breathing can stop for a prolonged period of time (often more than 10 seconds). These periods of lack of breathing are followed by sudden attempts to breathe. These attempts are accompanied by a change to a lighter stage of sleep. The result is fragmented sleep that is not restful, leading to excessive daytime drowsiness. Obstructive sleep apnea includes episodes of heavy snoring that begin soon after falling asleep. The snoring proceeds at a regular pace for a period of time, often becoming louder, but is then interrupted by a long silent period during which no breathing is taking place (apnea). The apnea is then interrupted by a loud snort and gasp and the snoring returns to its regular pace. This behavior recurs frequently throughout the night. During the apneic periods the oxygen level in the blood falls. Persistent low levels of oxygen (hypoxia) may cause many of the daytime symptoms. If the condition is severe enough, pulmonary hypertension may develop leading to right sided heart failure.



-==¤¥¥¥¤==- ICD-9-CM listings codes for support of medical necessity for gastric bypass (bariatric) surgery -==¤¥¥¥¤==-

Claims should include at least one of the primary diagnoses and the secondary diagnosis 278.01 (morbid obesity). Use of any ICD-9-CM code not listed in below will be denied. Obesity (278.00) is not in and of itself sufficient to be approved for surgery. The patient must have morbid obesity (278.01) AND another condition which was aggravated by the obesity.


Primary Diagnosis Codes

250.00 DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED

250.01 DIABETES MELLITUS WITHOUT COMPLICATION TYPE I NOT STATED AS UNCONTROLLED

250.02 DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE UNCONTROLLED

250.03 DIABETES MELLITUS WITHOUT COMPLICATION TYPE I UNCONTROLLED

250.10 DIABETES MELLITUS WITH KETOACIDOSIS TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED

250.11 DIABETES MELLITUS WITH KETOACIDOSIS TYPE I NOT STATED AS UNCONTROLLED

250.12 DIABETES MELLITUS WITH KETOACIDOSIS TYPE II OR UNSPECIFIED TYPE UNCONTROLLED

250.13 DIABETES MELLITUS WITH KETOACIDOSIS TYPE I UNCONTROLLED

250.20 DIABETES MELLITUS WITH HYPEROSMOLARITY TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED

250.21 DIABETES MELLITUS WITH HYPEROSMOLARITY TYPE I NOT STATED AS UNCONTROLLED

250.22 DIABETES MELLITUS WITH HYPEROSMOLARITY TYPE II OR UNSPECIFIED TYPE UNCONTROLLED

250.23 DIABETES MELLITUS WITH HYPEROSMOLARITY TYPE I UNCONTROLLED

250.30 DIABETES MELLITUS WITH OTHER COMA TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED

250.31 DIABETES MELLITUS WITH OTHER COMA TYPE I NOT STATED AS UNCONTROLLED

250.32 DIABETES MELLITUS WITH OTHER COMA TYPE II OR UNSPECIFIED TYPE UNCONTROLLED

250.33 DIABETES MELLITUS WITH OTHER COMA TYPE I UNCONTROLLED

250.40 DIABETES MELLITUS WITH RENAL MANIFESTATIONS TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED

250.41 DIABETES MELLITUS WITH RENAL MANIFESTATIONS TYPE I NOT STATED AS UNCONTROLLED

250.42 DIABETES MELLITUS WITH RENAL MANIFESTATIONS TYPE II OR UNSPECIFIED TYPE UNCONTROLLED

250.43 DIABETES MELLITUS WITH RENAL MANIFESTATIONS TYPE I UNCONTROLLED

250.50 DIABETES MELLITUS WITH OPHTHALMIC MANIFESTATIONS TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED

250.51 DIABETES MELLITUS WITH OPHTHALMIC MANIFESTATIONS TYPE I NOT STATED AS UNCONTROLLED

250.52 DIABETES MELLITUS WITH OPHTHALMIC MANIFESTATIONS TYPE II OR UNSPECIFIED TYPE UNCONTROLLED

250.53 DIABETES MELLITUS WITH OPHTHALMIC MANIFESTATIONS TYPE I UNCONTROLLED

250.60 DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED

250.61 DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS TYPE I NOT STATED AS UNCONTROLLED

250.62 DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS TYPE II OR UNSPECIFIED TYPE UNCONTROLLED

250.63 DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS TYPE I UNCONTROLLED

250.70 DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED

250.71 DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS TYPE I NOT STATED AS UNCONTROLLED

250.72 DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS TYPE II OR UNSPECIFIED TYPE UNCONTROLLED

250.73 DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS TYPE I UNCONTROLLED

250.80 DIABETES MELLITUS WITH OTHER SPECIFIED MANIFESTATIONS TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED

250.81 DIABETES MELLITUS WITH OTHER SPECIFIED MANIFESTATIONS TYPE I NOT STATED AS UNCONTROLLED

250.82 DIABETES MELLITUS WITH OTHER SPECIFIED MANIFESTATIONS TYPE II OR UNSPECIFIED TYPE UNCONTROLLED

250.83 DIABETES MELLITUS WITH OTHER SPECIFIED MANIFESTATIONS TYPE I UNCONTROLLED

250.90 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED

250.91 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION TYPE I NOT STATED AS UNCONTROLLED

250.92 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION TYPE II OR UNSPECIFIED TYPE UNCONTROLLED

250.93 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION TYPE I UNCONTROLLED

401.0 MALIGNANT ESSENTIAL HYPERTENSION

401.1 BENIGN ESSENTIAL HYPERTENSION

401.9 UNSPECIFIED ESSENTIAL HYPERTENSION

402.00 MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE

402.01 MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.10 BENIGN HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE

402.11 BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.90 UNSPECIFIED HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE

402.91 UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

403.00 MALIGNANT HYPERTENSIVE RENAL DISEASE WITHOUT RENAL FAILURE

403.01 MALIGNANT HYPERTENSIVE RENAL DISEASE WITH RENAL FAILURE

403.10 BENIGN HYPERTENSIVE RENAL DISEASE WITHOUT RENAL FAILURE

403.11 BENIGN HYPERTENSIVE RENAL DISEASE WITH RENAL FAILURE

403.90 UNSPECIFIED HYPERTENSIVE RENAL DISEASE WITHOUT RENAL FAILURE

403.91 UNSPECIFIED HYPERTENSIVE RENAL DISEASE WITH RENAL FAILURE

404.00 MALIGNANT HYPERTENSIVE HEART AND RENAL DISEASE WITHOUT HEART FAILURE OR RENAL FAILURE

404.01 MALIGNANT HYPERTENSIVE HEART AND RENAL DISEASE WITH HEART FAILURE

404.02 MALIGNANT HYPERTENSIVE HEART AND RENAL DISEASE WITH RENAL FAILURE

404.03 MALIGNANT HYPERTENSIVE HEART AND RENAL DISEASE WITH HEART FAILURE AND RENAL FAILURE

404.10 BENIGN HYPERTENSIVE HEART AND RENAL DISEASE WITHOUT HEART FAILURE OR RENAL FAILURE

404.11 BENIGN HYPERTENSIVE HEART AND RENAL DISEASE WITH HEART FAILURE

404.12 BENIGN HYPERTENSIVE HEART AND RENAL DISEASE WITH RENAL FAILURE

404.13 BENIGN HYPERTENSIVE HEART AND RENAL DISEASE WITH HEART FAILURE AND RENAL FAILURE

404.90 UNSPECIFIED HYPERTENSIVE HEART AND RENAL DISEASE WITHOUT HEART FAILURE OR RENAL FAILURE

404.91 UNSPECIFIED HYPERTENSIVE HEART AND RENAL DISEASE WITH HEART FAILURE

404.92 UNSPECIFIED HYPERTENSIVE HEART AND RENAL DISEASE WITH RENAL FAILURE

404.93 UNSPECIFIED HYPERTENSIVE HEART AND RENAL DISEASE WITH HEART FAILURE AND RENAL FAILURE

405.01 MALIGNANT RENOVASCULAR HYPERTENSION

405.09 OTHER MALIGNANT SECONDARY HYPERTENSION

405.11 BENIGN RENOVASCULAR HYPERTENSION

405.19 OTHER BENIGN SECONDARY HYPERTENSION

405.91 UNSPECIFIED RENOVASCULAR HYPERTENSION

405.99 OTHER UNSPECIFIED SECONDARY HYPERTENSION

414.00 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT

414.01 CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY

414.02 CORONARY ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT

414.03 CORONARY ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT

414.04 CORONARY ATHEROSCLEROSIS OF ARTERY BYPASS GRAFT

414.05 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT

416.9 CHRONIC PULMONARY HEART DISEASE UNSPECIFIED

425.4 OTHER PRIMARY CARDIOMYOPATHIES

425.9 SECONDARY CARDIOMYOPATHY UNSPECIFIED

428.0 CONGESTIVE HEART FAILURE UNSPECIFIED

428.9 HEART FAILURE UNSPECIFIED

492.0 EMPHYSEMATOUS BLEB

492.8 OTHER EMPHYSEMA

493.00 EXTRINSIC ASTHMA UNSPECIFIED

493.01 EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS

493.02 EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION

493.10 INTRINSIC ASTHMA UNSPECIFIED

493.11 INTRINSIC ASTHMA WITH STATUS ASTHMATICUS

493.12 INTRINSIC ASTHMA WITH (ACUTE) EXACERBATION

493.20 CHRONIC OBSTRUCTIVE ASTHMA UNSPECIFIED

493.21 CHRONIC OBSTRUCTIVE ASTHMA WITH STATUS ASTHMATICUS

493.22 CHRONIC OBSTRUCTIVE ASTHMA WITH (ACUTE) EXACERBATION

493.90 ASTHMA UNSPECIFIED

493.91 ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS

493.92 ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION

494.0 BRONCHIECTASIS WITHOUT ACUTE EXACERBATION

494.1 BRONCHIECTASIS WITH ACUTE EXACERBATION

496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED

530.11 REFLUX ESOPHAGITIS

530.19 OTHER ESOPHAGITIS

715.09 OSTEOARTHROSIS GENERALIZED INVOLVING MULTIPLE SITES

715.15 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING PELVIC REGION AND THIGH

715.16 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING LOWER LEG

715.25 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING PELVIC REGION AND THIGH

715.26 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING LOWER LEG

715.35 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING PELVIC REGION AND THIGH

715.36 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING LOWER LEG

715.89 OSTEOARTHROSIS INVOLVING OR WITH MULTIPLE SITES BUT NOT SPECIFIED AS GENERALIZED

715.95 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING PELVIC REGION AND THIGH

715.96 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING LOWER LEG

780.51 INSOMNIA WITH SLEEP APNEA

780.57 OTHER AND UNSPECIFIED SLEEP APNEA


Secondary Diagnosis Code

278.01 MORBID OBESITY