Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 11.03.02s


Attachment:A

Policy #:11.03.02s

Description:Body Mass Index (BMI) Charts

Title:Bariatric Surgery



BODY MASS INDEX (BMI) CHARTS
These tables were adapted from the clinical guidelines for the identification, evaluation, and treatment of overweight and obese adults and were prepared by the National Institutes of Health (NIH), National Heart, Lung, and Blood Institute.

BODY MASS INDEX (BMI) CHART I: A RANGE OF UP TO 287 POUNDS
To use this table, find the appropriate height in the left-hand column. Move across the row to a given weight. The number at the top of the column is the BMI for the selected height and weight. Pounds have been rounded off.
BMI
Height (inches)1920212223242526272829303132333435
589196100105110115119124129134138143148153158162167
599499104109114119124128133138143148153158163168173
6097102107112118123128133138143148153158163168174179
61100106111116122127132137143148153158164169174180185
62104109115120126131136142147153158164169175180186191
63107113118124130135141146152158163169175180186191197
64110116122128134140145151157163169174180186192197204
65114120126132138144150156162168174180186192198204210
66118124130136142148155161167173179186192198204210216
67121127134140146153159166172178185191198204211217223
68125131138144151158164171177184190197203210216223230
69128135142149155162169176182189196203209216223230236
70132139146153160167174181188195202209216222229236243
71136143150157165172179186193200208215222229236243250
72140147154162169177184191199206213221228235242250258
73144151159166174182189197204212219227235242250257265
74148155163171179186194202210218225233241249256264272
75152160168176184192200208216224232240248256264272279
76156164172180189197205213221230238246254263271279287
Body Weight (pounds)


BODY MASS INDEX CHART II: A RANGE OF UP TO 443 POUNDS
To use this table, find the appropriate height in the left-hand column. Move across the row to a given weight. The number at the top of the column is the BMI for the selected height and weight. Pounds have been rounded off.
BMI
Height (inches)36373839404142434445464748495051525354
58172177181186191196201205210215220224229234239244248253258
59178183188193198203208212217222227232237242247252257262267
60184189194199204209215220225230235240245250255261266271276
61190195201206211217222227232238243248254259264269275280285
62196202207213218224229235240246251256262267273278284289295
63203208214220225231237242248254259265270278282287293299304
64209215221227232238244250256262267273279285291296302308314
65216222228234240246252258264270276282288294300306312318324
66223229235241247253260266272278284291297303309315322328334
67230236242249255261268274280287293299306312319325331338344
68236243249256262269276282289295302308315322328335341348354
69243250257263270277284291297304311318324331338345351358365
70250257264271278285292299306313320327334341348355362369376
71257265272279286293301308315322329338343351358365372379386
72265272279287294302309316324331338346353361368375383390397
73272280288295302310318325333340348355363371378386393401408
74280287295303311319326334342350358365373381389396404412420
75287295303311319327335343351359367375383391399407415423431
76295304312320328336344353361369377385394402410418426435443
Body Weight (pounds)

Version Effective Date: 10/01/2019
Version Issued Date: 10/21/2019
Version Reissued Date: 01/09/2020

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.