Prior Authorization : Services Requiring Prior Authorization

Bariatric Surgery

All covered bariatric surgery procedures require PA. A bariatric procedure that does not meet the following PA approval criteria is considered a noncovered service.

Prior Authorization Approval Criteria for Bariatric Surgery

PA requests for bariatric surgery may be approved if one of the following criteria is met:

• The member has a BMI greater than or equal to 35 kg/m² and inadequately controlled Type 2 diabetes mellitus despite appropriate therapy with at least two medications of different drug classes, either oral or injectable.
• The member has a BMI greater than or equal to 40 kg/m² and one of the following:
  • Moderate to severe obstructive sleep apnea
  • Type 2 diabetes mellitus
  • Medically refractory hypertension (blood pressure consistently greater than 140/90 mmHg despite the concurrent use of three anti-hypertensive agents of different drug classes)
  • Obesity-related cardiomyopathy
  • Pickwickian syndrome (obesity hypoventilation syndrome)
• The member has a BMI greater than or equal to 50 kg/m² and mechanical arthropathy with documented functional impairment by a licensed physical therapist.

In addition to one of the above criteria, the member is required to meet all of the following criteria:

• The member is 18 years of age or older.
• The member has been obese for at least five years.
• Adequate prior attempts to lose weight or maintain weight loss have failed, or, for members whose prior attempts at weight loss have been deemed absent or inadequate, a six-month medically supervised weight loss program has been undertaken.

  Note: An acceptable medically supervised weight loss program is weight loss guidance that is provided in a clinical setting by a licensed healthcare professional on repeated occasions over at least a six-month period.

  These required weight loss attempts by the member are prior to and separate from the bariatric assessment and six-month multi-disciplinary surgical preparatory regimen described below.

• The member has been determined to be an appropriate surgical candidate based on an evaluation by the PCP or other appropriate provider (that is, the member does not have cardiopulmonary disease that would make surgical risk prohibitive or other identifiable contraindication to elective surgery).
• The member has abstained from alcohol abuse and other substance abuse for at least six months.
• The member has undergone a multidisciplinary bariatric team assessment within 12 months of the proposed surgery and has been found by consensus to be an appropriate surgical candidate, and there is documentation that supports that the member understands risks, benefits, expected outcomes, alternatives, and required lifestyle changes. The bariatric assessment, at a minimum, must include the following:
  • The member's medical history, physical exam results, and proposed plan by the bariatric surgeon
  • A psychological or psychiatric evaluation to determine readiness for surgery and identify any mental health barriers to the success of the proposed surgery. If a comorbid psychiatric diagnosis exists, an assessment of adequate stability must come from the treating mental health provider.
  • At least six consecutive months of documented participation and progress in a multi-disciplinary surgical preparatory regimen that includes dietary counselling, supervised exercise, and behavior modification to assess the member's ability to comply with the necessary post-operative lifestyle changes and to signal surgical readiness. Records must document member compliance with this multidisciplinary surgical preparatory regimen. Accordingly, the member must not have a net weight gain during this period greater than what is explainable as a normal fluctuation (up to five pounds) or otherwise attributable to a recognized medical condition (such as edema). If applicable, members should be strongly encouraged to stop smoking preoperatively.
• The member has been evaluated for and does not have a contributing endocrinopathy.

Note: Bariatric surgery is not required to be performed at an American Society for Metabolic and Bariatric Surgery-certified Center of Excellence or Level 1 Bariatric Surgery Center; however, centers and teams performing bariatric surgery must be experienced in the management of metabolic surgery and obesity-related comorbidities.

Prior Authorization Approval Criteria for Revision of Bariatric Surgery

PA requests for revision of bariatric surgery may be approved if one of the following criteria is met:

• Removal of a gastric band is considered medically necessary and is recommended by the member's physician.
• Surgery to correct complications of a prior bariatric surgery is considered medically necessary for such issues as obstruction, stricture, erosion, band slippage, or port or tubing malfunction.

Note: Revision of a primary bariatric surgery procedure that has failed (that is, surgery was initially successful at inducing weight loss, then the member regained weight) due to dilation of the gastric pouch, a dilated gastrojejunal stoma, or dilatation of the gastrojejunostomy anastomosis is not covered if, as in most cases of dilation, the primary cause for these remote post-surgical changes is noncompliance (that is, overeating).

Prior Authorization Approval Criteria for Repeat Bariatric Surgery

PA requests for repeat bariatric surgery may be approved for members whose initial bariatric surgery was considered medically necessary and who meet one of the following medical necessity criteria:

• Replacement of an adjustable band is considered medically necessary because there are complications (for example, port leakage or slippage) that cannot be corrected with band manipulation or adjustments.
• Conversion from an adjustable band to a sleeve gastrectomy, Roux-en-Y gastric bypass, or biliopancreatic diversion with duodenal switch is considered medically necessary for a member who has been compliant with a prescribed nutrition and exercise program following the band procedure but who has complications that cannot be corrected with band manipulation, adjustments, or replacement.

Prior Authorization Documentation

When requesting PA for bariatric surgery, revision of bariatric surgery, or repeat bariatric surgery, providers are required to submit all of the following:

• A completed PA/RF
• A completed PA/PA
• Documentation that fully supports the approval criteria

Length of Authorization

The length of authorization for an approved PA request for bariatric surgery, revision of bariatric surgery, or repeat bariatric surgery is 12 months.