For Dates of Service Before September 1, 2011

Bariatric Surgery

Criteria for Coverage of All Bariatric Procedures

Comorbidities

Providers are required to submit with a PA request clinically documented evidence that a continued comorbid clinical status will lead to serious impairment of the member's health, and treatment of the comorbid condition for a minimum of three months has not improved the health risks and impairments.

Such comorbid conditions undergoing current appropriate therapy trials would include, for example, but not be restricted to, congestive heart failure, recurrent venous thrombosis with or without pulmonary emboli, uncontrolled diabetes mellitus or demonstrated coronary artery disease with hemodynamically significant arteriolar occlusion leading to documented myocardial dysfunction.

Facility Requirements

BadgerCare Plus requires all bariatric surgery procedures to be performed at a facility that is Medicaid certified and meets one of the following requirements:

• The center has been certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center.
• The facility has been certified by the ASBS as a Bariatric Surgery Center of Excellence.

Claims for bariatric services from a hospital that does not meet the above criteria will be denied.

A current list of approved facilities in included in the following table. As this list may change at any time, providers are advised to check for revisions to the list at cms.hhs.gov/MedicareApprovedFacilitie/BSF/list.asp.

Laparoscopic Adjustable Gastric Banding

BadgerCare Plus covers LAGB (CPT procedure codes 43770-43774). Coverage of LAGB is subject to the same approval criteria as other covered bariatric procedures.

Prior Authorization Approval Criteria

All BadgerCare Plus-covered bariatric surgery procedures (CPT procedure codes 43644-43645, 43659, 43770-43774, 43842-43843, 43846-43848) require PA. As a reminder, PA requests must be submitted by physicians, and claims must be submitted by facilities. If a PA is not on file when the claim is submitted, the claim will be denied. The approval criteria for PA requests for BadgerCare Plus-covered bariatric surgery procedures include all of the following:

• The member must have one of the following:
  • A BMI of 40 or greater (include clinical documentation that a continued morbidly obese status will lead to serious impairment of the member's health because of comorbid conditions that cannot be optimally corrected with current therapy) with a demonstrated and documented trial of a minimum of three months.
    1. Such comorbid conditions undergoing current appropriate therapy would include, but not be limited to, congestive heart failure, recurrent venous thrombosis with or without pulmonary emboli, uncontrolled diabetes mellitus, or demonstrated coronary artery disease with hemodynamically significant arteriolar occlusion leading to myocardial dysfunction.
    2. A three-month period of a physician-supervised program including dietary counseling, behavioral modification, and supervised exercise, plus a psychiatric evaluation prior to surgery would be required for those members whose clinical status is stable. This would provide time to stabilize the member's current clinical status, and educate the member through behavioral modification related to eating habits, appropriate exercise, and psychological support to assure the greatest success with weight control after surgery.
  • A BMI between 35 and 39 with documented high-risk comorbid medical conditions that have not responded to medical management and are a threat to life, such as, but not limited to clinically significant obstructive sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy, coronary heart disease, or medically refractory hypertension.
• Documentation that the member has attempted weight loss in the past without successful long-term weight reduction. These attempts may include, but are not limited to, diet restrictions or supplements, behavior modification, physician-supervised weight loss plans, physical activity programs, commercial or professional programs, and pharmacological therapy.
• For all members who are stable without documented life-threatening comorbidities, documentation must be presented that the member has clinically documented evidence of a minimum of six months of demonstrated adherence to a physician-supervised weight management program including at least three consecutive months of participation in a weight management program prior to the date of surgery in order to improve surgical outcomes, reduce the potential for surgical complications and establish the member's ability to comply with post-operative medical care and dietary restrictions. A physician's summary letter is not sufficient documentation. Documentation must include assessment of the member's participation and progress throughout the course of the program. The member must also agree to attend a medically supervised post-operative weight management program for a minimum of six months post-surgery for the purpose of ongoing dietary, physical activity, behavioral/psychological, and medical education monitoring.
• The member should receive a preoperative evaluation by an experienced and knowledgeable multidisciplinary bariatric treatment team composed of health care providers with medical, nutritional, and psychological experience. This evaluation must include, at a minimum:
  • A complete history and physical examination, specifically evaluating for obesity-related comorbidities that would require preoperative management.
  • Evaluation for any correctable endocrinopathy that might contribute to obesity.
  • Psychological or psychiatric evaluation and clearance to determine the stability of the member in terms of tolerating the operative procedure and postoperative sequelae, as well as the likelihood of the member participating in an ongoing weight management program following surgery.
  • Members receiving active treatment for a psychiatric disorder must receive evaluation by their treatment provider prior to bariatric surgery and be cleared for bariatric surgery.
  • Dietary assessment and counseling.
• The member must be 18 years of age or older and have completed growth.
• The member must have a BMI of 50 or less for approval of LAGB (43770-43774).

All of the following must be included in the PA request:

• A completed PA/RF.
• A completed PA/PA.
• Clinical documentation supporting the criteria.

The following procedures are considered investigational, inadequately studied, or unsafe and therefore are not covered:

• Gastric balloon.
• Biliopancreatic bypass.
• Loop gastric bypass.