Bariatric Surgery Prior Authorization

• Age between 21-59 years of age (Age 18-20 only laparoscopic adjust gastric banding, LAGB)
• Body Mass Index (BMI) must be equal to or greater than 35
• Medical conditions/Co-morbidities: must have at least ONE of the following documented in the medical record:
  • Diabetes Mellitus
  • Severe degenerative Joint Disease of a major weight-bearing joint(s) (such as knees or hips) AND is currently a candidate for joint replacement surgery as soon as weight loss is achieved. Copies of current radiographic studies (plain films) may be requested in addition to the radiologist’s reports *Medical records, including an orthopedic surgery consult documenting the need for a joint replacement (knee or hip), and radiology reports are required. Actual current plain films (X-ray images) may be required
  • Other rare co-morbid conditions (such as pseudo tumor cerebri) in which there is medical evidence that bariatric surgery is medically necessary, and the benefits of bariatric surgery outweigh the risk of surgical mortality
  • Members referred to an accredited facility by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) will be evaluated for clinical eligibility for Bariatric Surgery.
  • The member’s CHPW care manager will assist with care coordination.

EXCLUSIONS: Enrollees with diagnosis of multiple sclerosis, pregnancy, refractory depression or active substance abuse.

Review Policy MM145 for details of requirements, eligibility, and process ➜

1. History and physical examination notes
2. Problem list
3. Medication list
4. List of diets and weight loss interventions that the patient has previously tried and the results
5. Detailed records demonstrating compliance with weight loss program
6. Details of any specific needs related to risk/trauma/cultural etc.
7. Additional documentation depending on diagnosis:
   1. If the patient has Diabetes
      1. Blood sugars and Hemoglobin A1C that lead to diagnosis of diabetes
      2. Recent HbA1C

* Diabetes diagnosis requires a history of one of the following:

• Symptomatic diabetes requires both the following criteria:
  • Symptoms of diabetes (classic symptoms include polyuria, polydipsia, and unexplained weight loss)
  • Plasma glucose concentration ≥200 mg/dl (11.1 mmol/l) (at any time of day without regard to time of last meal)
• Asymptomatic diabetes requires that the patient is not pregnant or on corticosteroid medication and meets two of the following criteria or the FPG criteria are met on two different days:
  • FPG values ≥126 mg/dL (7.0 mmol/L)
  • Two-hour plasma glucose values of ≥200 mg/dL (11.1 mmol/L) during a 75 g OGTT (This test is not recommended by the American Diabetes Association for routine clinical use).
  • HbA1C value ≥6.5 percent (48 mmol/mol).

1. 1. If the patient has end stage joint disease of the knee or hip:
      1. Notes from orthopedic surgery detailing that the patient needs a joint replacement of knee or hip when the weight loss is achieved
      2. Imaging reports of the affected joint.

* End Stage Joint Disease of Major Weight-Bearing Joint(s) requires all the following criteria:

• Severe osteoarthritis of the knees or hips
• Records from orthopedic surgeon show that the patient will qualify for arthroplasty as soon as the BMI is less than 40
• Radiographic imaging shows Kellgren-Lawrence grade 3 or 4

1. 1. If the diagnosis is pseudotumor cerebri or other rare condition helped by weight loss surgery:
      1. Specific notes related to that disease are required
      2. Other treatments that have been tried and the patient’s response to those treatments

During the six-month enrollment in Stage 2, the following activities are expected in Stage 2 and will be assessed prior to authorization for Stage 3 (see criteria for Stage 3 below):

• Participation in a weight loss program under the supervision of a licensed medical provider with sustained weight loss of at least 5% of body weight. If weight loss is not achieved within the 180 days, the authorization is cancelled, and the member must resubmit a request for Stage 2. Initial body weight is the client’s weight at the first evaluation appointment for the most recent Stage 2 enrollment at an accredited facility by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)
• Meet with Primary Care Provider once monthly to review weight management progress. Provider must document the member’s compliance in keeping scheduled appointments and the progress towards weight loss. For diabetic enrollees, the provider must document efforts in diabetic control or stabilization.
• Meet with a Registered Dietician (R.D.) for counseling twice monthly for at least 6 months. The must document the member’s compliance in keeping scheduled appointments and the progress towards weight loss.
• The R.D. must assess and certify the client’s ability to comply with postoperative requirements such as lifelong required dietary changes and regular follow-up
• Keep a journal of active participation in the medically structured weight loss regimen
• The member must undergo a comprehensive psychosocial evaluation performed by a psychiatrist, psychologist, licensed psychiatric ARNP, or licensed independent social worker with a minimum of two years post-masters’ experience in a mental health setting. The evaluation must include:
  • Evaluation for presence of substance abuse problems or psychiatric illness which would preclude the client from participating in pre-surgical dietary requirements or postsurgical lifestyle changes, and
  • Documentation that if the client has a history of psychiatric illness, the client has been stable for at least 6 months, and
  • Documentation that if there is a history of drug and alcohol abuse, the client has been clean and sober for at least one year
  • The member must undergo an internal medicine evaluation performed by an internist to assess the client’s peri-operative condition and mortality risk and provide CHPW with a copy of the results
  • Undergo a surgical evaluation by the surgeon who will be performing the bariatric surgery and provide CHPW with a copy of the results

If a member has been previously approved and enrolled in Stage 2 for six months bud did not achieve the required weight loss to meet criteria for Stage 3, the member can submit as second request for approval for Stage 2.

If a member has had two enrollment periods in Stage 2, the initial weight that will be used to determine if the member meets the criteria for Stage 3 will be the weight at the first appointment of the second enrollment of Stage 2. This request for a second enrollment in Stage 2 may be considered if all the following criteria are met:

• The member has met and continues to meet all the initial criteria for Stage 2
• The member lost at least 2.5% of the body weight from the beginning to the end of the first six-month enrollment in Stage 2
• The member attended all the required appointments during the first six-month enrollment in Stage 2
• The member has not had more than one previous enrollment at Stage 2. (Two is the maximum number of enrollments possible for Stage 2)

1. Ongoing compliance with pre-surgery care plan
2. Surgery must be at a Hospital accredited by the Metabolic and Bariatric Surgery Accreditation
   and Quality Improvement Program (MBSAQIP)
3. Surgeon must have a valid medical license in the State of Washington
4. Surgical procedure must have conclusive evidence which supports its use
5. The client must undergo an internal medicine evaluation performed by an internist to assess the client’s peri-operative condition and mortality risk and provide CHPW with a copy of the results
6. Undergo a surgical evaluation by the surgeon who will be performing the bariatric surgery and provide CHPW with a copy of the results
7. Documentation of the member fulfilling of all requirements during the first six months of the most recent enrollment in Stage 2 must be submitted for CHPW Prior Authorization (PA) review including all of the following:
   1. Participate in a six month weight loss program under the supervision of a licensed medical provider with monthly visits to the medical provider, counseling twice a month
      with a registered dietician referred to by the treating provider or surgeon and show compliance in keeping scheduled appointments and demonstrate progress in weight loss by serial recordings documented by both medical provider and registered dietician. The R.D. must assess and certify the client’s ability to comply with postoperative requirements such as lifelong required dietary changes and regular follow-up. For diabetic enrollees, the provider must document efforts in diabetic control or stabilization.
   2. Lose at least 5% of body weight and maintain weight-loss until time of surgery. The initial body weight is the client’s weight at the first evaluation appointment for the most recent Stage 2 enrollment at the accredited Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
   3. Keep a journal of active participation in the medically structured weight loss regimen
   4. Undergo a comprehensive psychosocial evaluation performed by a psychiatrist, licensed psychiatric ARNP, or licensed independent social worker with a minimum of two years post-masters’ experience in a mental health setting. The evaluation must include:
      1. Evaluation for presence of substance abuse problems or psychiatric illness which would preclude the client from participating in pre-surgical dietary requirements or postsurgical lifestyle changes, and
      2. Documentation that if the client has a history of psychiatric illness, the client has been stable for at least 6 months, and
      3. Documentation that if there is a history of drug and alcohol abuse, the client has been clean and sober for at least one year
      4. An assessment and certification of the client’s ability to comply with the postoperative requirements such as lifelong required dietary changes and regular follow-up.