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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the surgical management for the treatment of morbid obesity is considered reasonable and 
necessary for all nationally covered bariatric surgical procedures and Laproscopic sleeve gastrectomy when 
ALL of the following conditions are met and recorded in the medical record: 
 
    The patient meets the definition of morbid obesity which is defined as a body mass index (BMI) > 35 and 
comorbid conditions exist (e.g., hypertensive cardiovascular disease, pulmonary/respiratory disease, diabetes, 
sleep apnea or degenerative arthritis of weight-bearing joints). Documentation of the level of severity of the 
comorbid existing condition must be included in the patients medical record; AND 
    The patient has been previously unsuccessful with medical treatment for obesity; AND 
    Treatable metabolic causes for obesity (e.g., adrenal or thyroid disorders) have been ruled out or have been 
clinically treated if present. 
 
Unsuccessful Medical Treatment for Obesity 
 
With or without bariatric surgery, successful obesity management requires adoption and lifelong practice of 
healthy eating and physical exercise (i.e. lifestyle modification) by the obese patient. Without adequate patient 
motivation and/or skills needed to make such lifestyle modifications, the benefit of bariatric surgical 
procedures is severely jeopardized and not medically reasonable or necessary. Patients considering bariatric 
surgical options must have been provided with knowledge and tools needed to achieve such lifelong lifestyle 
changes and must be capable and willing to undergo the changes. 
 
For the purposes of this LCD, a patient will be deemed to have been unsuccessful with medical treatment of 
obesity if all of the following minimal requirements are met per documentation in the medical record: 
 
    The patient has BMI = 35 at the time of surgery. 
    The patient has been provided with knowledge and tools needed to achieve such lifelong lifestyle changes, 
exhibits understanding of the needed changes and has demonstrated to clinicians involved in his or her care to 
be capable and willing to undergo the changes. 
    The patient has made a diligent effort to achieve healthy body weight with such efforts described in the medical record and certified by the operating surgeon. 
    The patient has failed to maintain a healthy weight despite adequate participation in a structured dietary 
program overseen by one of the following: 
        Physician (MD or DO). 
        Registered dietician (RD). 
        Board certified specialist in pediatric nutrition (CSP). 
        Board certified specialist in renal nutrition (CSR). 
        Fellow of the American Dietetic Association (FADA). 
 
You can find this information in the Local Coverage Determination (LCD) Surgical Management of Morbid 
Obesity L33411. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.