Changes to Bariatric Surgery Prior Authorization Guidelines

Update August 2011

No. 2011-44

Affected Programs: BadgerCare Plus, Medicaid To: Hospital Providers, Physician Assistants, Physician Clinics, Physicians, HMOs and Other Managed Care Programs

Changes to Bariatric Surgery Prior Authorization Guidelines This ForwardHealth Update introduces the updated prior authorization (PA) requirements for bariatric surgery effective for PA requests received on and after September 1, 2011.



The member has been evaluated for adequacy of prior efforts to lose weight. If there have been no or inadequate prior dietary efforts, the member must undergo six months of a medically supervised weight reduction program. This is separate from and not

Effective for prior authorization (PA) requests received on

satisfied by the dietician counseling required as part of

and after September 1, 2011, ForwardHealth has updated

the evaluation for bariatric surgery.

criteria for coverage of bariatric surgical procedures. Bariatric



The member has been free of illicit drug use and alcohol

surgery is covered under the criteria listed in this

abuse or dependence for the six months prior to

ForwardHealth Update for Wisconsin Medicaid and

surgery.

BadgerCare Plus programs.

Prior Authorization Approval Criteria

 

The member has been obese for at least five years. The member has had a medical evaluation from the member’s primary care physician to assess preoperative

The approval criteria for PA requests for covered bariatric

condition and surgical risk and found the member to be

surgery procedures include all of the following:

an appropriate candidate.



The member has a body mass index greater than 35 with



The member has received a preoperative evaluation by

at least one documented high-risk, life-limiting

an experienced and knowledgeable multidisciplinary

comorbid medical conditions capable of producing a

bariatric treatment team composed of health care

significant decrease in health status that are

providers with medical, nutritional, and psychological

demonstrated to be unresponsive to appropriate

experience. This evaluation must include, at a minimum:

treatment. There is evidence that significant weight loss

 A complete history and physical examination,

can substantially improve the following comorbid

specifically evaluating for obesity-related

conditions:

comorbidities that would require preoperative

 Sleep apnea.  Poorly controlled Diabetes Mellitus while

management.

compliant with appropriate medication regimen.

 Poorly controlled hypertension while compliant with appropriate medication regimen.

 Obesity-related cardiomyopathy.

 Evaluation for any correctable endocrinopathy that might contribute to obesity.

 Psychological or psychiatric evaluation to determine appropriateness for surgery, including an evaluation of the stability of the member in terms of tolerating the operative procedure and postoperative sequelae, Department of Health Services

as well as the likelihood of the member participating in an ongoing weight management

The approval criteria for PA requests for ForwardHealth-

program following surgery.

covered bariatric surgery procedures are also included in

 For members receiving active treatment for a psychiatric disorder, an evaluation by his or her

Attachment 1 of this Update.

treatment provider prior to bariatric surgery. The

Covered Services

treatment provider is required to clear the member

Attachment 2 contains a chart that lists the bariatric

for bariatric surgery.

procedures covered by Wisconsin Medicaid. All bariatric

 At least three consecutive months of participation

surgery procedures require PA. A bariatric procedure that

in a weight management program prior to the date

does not meet the PA approval criteria is considered a

of surgery, including dietary counseling, behavioral

noncovered service.

modification, and supervised exercise, in order to improve surgical outcomes, reduce the potential for

Length of Authorization

surgical complications, and establish the candidate’s

The length of authorization for an approved PA request for

ability to comply with post-operative medical care

bariatric surgery is six months.

and dietary restrictions. A physician’s summary letter is not sufficient documentation.

 Agreement by the member 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 and monitoring.



The member is 18 years of age or older and has completed growth.



The member has not had bariatric surgery before or there is clear evidence of compliance with dietary modification and supervised exercise, including appropriate lifestyle changes, for at least two years.



The bariatric center where the surgery will be performed has been approved by Centers for Medicare and Medicaid Services/American Society for Bariatric Surgery (ASBS) guidelines as a Center of Excellence and meet 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. A current list of approved facilities is available at www.cms.gov/MedicareApprovedFacilitie/BSF/list.asp.

Services That are Not Covered ForwardHealth does not cover the following services because they are investigational, inadequately studied, or unsafe:

   

Vertical banded gastroplasty. Gastric balloon. Loop gastric bypass. Open adjusted gastric banding.

How to Submit Prior Authorization Requests Providers may submit PA requests via the ForwardHealth Portal. Providers can upload electronically completed PA attachments and additional, required documentation. Providers may also submit paper PA requests for bariatric surgery. Paper PA requests must include:



A completed Prior Authorization Request Form (PA/RF), F-11018 (10/08).



A completed Prior Authorization/Physician Attachment (PA/PA), F-11016 (10/08).



Documentation supporting the criteria in the “Prior Authorization Approval Criteria” section of this Update.

Providers may submit paper PA requests by fax to ForwardHealth at (608) 221-8616 or by mail to:

ForwardHealth Provider Information  August 2011  No. 2011-44

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ForwardHealth Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088

Information Regarding Managed Care Organizations This Update contains fee-for-service policy and applies to services members receive on a fee-for-service basis only. For managed care policy, contact the appropriate managed care organization. Managed care organizations are required to provide at least the same benefits as those provided under fee-for-service arrangements. This Update was issued on 08/22/2011 and information contained in this Update was incorporated into the Online Handbook on 09/09/2011.

The ForwardHealth Update is the first source of program policy and billing information for providers. Wisconsin Medicaid, BadgerCare Plus, SeniorCare, and Wisconsin Chronic Disease Program are administered by the Division of Health Care Access and Accountability, Wisconsin Department of Health Services (DHS). The Wisconsin Well Woman Program is administered by the Division of Public Health, Wisconsin DHS. For questions, call Provider Services at (800) 947-9627 or visit our Web site at www.forwardhealth.wi.gov/. P-1250

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ATTACHMENT 1 Prior Authorization Approval Criteria The approval criteria for prior authorization (PA) requests for covered bariatric surgery procedures include all of the following:



The member has a body mass index greater than 35 with at least one documented high-risk, life-limiting comorbid medical conditions capable of producing a significant decrease in health status that are demonstrated to be unresponsive to appropriate treatment. There is evidence that significant weight loss can substantially improve the following comorbid conditions:

    

Sleep apnea. Poorly controlled Diabetes Mellitus while compliant with appropriate medication regimen. Poorly controlled hypertension while compliant with appropriate medication regimen. Obesity-related cardiomyopathy.

The member has been evaluated for adequacy of prior efforts to lose weight. If there have been no or inadequate prior dietary efforts, the member must undergo six months of medically supervised weight reduction program. This is separate from and not satisfied by the dietician counseling required as part of the evaluation for bariatric surgery.

  

The member has been free of illicit drug use and alcohol abuse or dependence for the six months prior to surgery. The member has been obese for at least five years. The member has had medical evaluation from the member’s primary care physician that assessed his or her preoperative condition and surgical risk and found the member to be an appropriate candidate.



The member has received 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 to determine appropriateness for surgery, including an evaluation of 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.

 For members receiving active treatment for a psychiatric disorder, an evaluation by his or her treatment provider prior to bariatric surgery. The treatment provider is required to clear the member for bariatric surgery.

 At least three consecutive months of participation in a weight management program prior to the date of surgery, including dietary counseling, behavioral modification, and supervised exercise, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the candidate’s ability to comply with post-operative medical care and dietary restrictions. A physician’s summary letter is not sufficient documentation.

 Agreement by the member 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 and monitoring.

 

The member is 18 years of age or older and has completed growth. The member has not had bariatric surgery before or there is clear evidence of compliance with dietary modification and supervised exercise, including appropriate lifestyle changes, for at least two years.

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

The bariatric center where the surgery will be performed has been approved by Centers for Medicare and Medicaid Services/American Society for Bariatric Surgery (ASBS) guidelines as a Center of Excellence and meet 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. A current list of approved facilities is available at www.cms.gov/MedicareApprovedFacilitie/BSF/list.asp.

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ATTACHMENT 2 Covered Bariatric Surgery Procedures CPT* Procedure Code 43644

Description Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)

43645 43770**

with gastric bypass and small intestine reconstruction to limit absorption Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components)

43771**

revision of adjustable gastric restrictive device component only

43772**

removal of adjustable gastric restrictive device component only

43773**

removal and placement of adjustable gastric restrictive device component only

43774**

removal of adjustable gastric restrictive device and subcutaneous port components

43775

longitudinal gastrectomy (ie, sleeve gastrectomy)

43843

Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than verticalbanded gastroplasty

43846

Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy

43847 43848

with small intestine reconstruction to limit absorption Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)

* CPT = Current Procedural Terminology. ** The member must have a body mass index less than or equal to 50 to receive prior authorization for procedure codes 43770-43774.

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