Bariatric surgery is considered medically necessary when it is used as a treatment for medical conditions that were caused by or worsened by the patient’s obesity. These conditions must be so severe that the benefits of eventual weight loss clearly outweigh the risks associated with bariatric surgery.
Bariatric surgery is not considered beneficial if the primary purpose is weight loss for its own sake, for cosmetic reasons, to correct psychological problems with poor body image, or simply because the patient prefers surgery to other traditional forms of weight loss.
Age limits on bariatric surgery for adolescents extend to female patients who are 13 years old or older and are menstruating, and for male patients who are 15 years old or older.
Pre-authorization documentation used to determine eligibility for bariatric surgery must cover all of the following:
- No significant contraindications that would suggest bariatric surgery would endanger the health of the patient.
- Documentation provided for prior authorization must attest that none of the following additional contraindications exist:
- Inflammatory bowel disease, chronic pancreatitis, cirrhosis, portal hypertension, abnormalities of the gastrointestinal tract, or endocrine causes of obesity.
- Long-term steroid treatment.
- Malignant cancer
- Significant psychological disorders that would be worsened or interfere with the post-operative management of the patient.
- Pregnancy, or plans to become pregnant within 18 months.
- Non-compliance with medical treatment.
- Bariatric surgery may be prior authorized when the patient meets all of the following criteria:
- The patient is a female at least 13 years of age and menstruating, or a male at least 15 years of age. Clients 20 years of age and younger must also have reached a Tanner stage IV plus 95 percent of adult height based on bone age, and must have a body mass index (BMI) of greater than or equal to 40 kg/m2. Clients 21 years of age or older must have a BMI of greater than or equal to 35 kg/m2.
- The patient, no matter what age, has at least one major comorbid condition, such as:
- Congestive heart failure
- Obesity-related hypoventilation
- Sleep apnea
- Pseudotumor cerebri
- Or two major comorbid conditions, such as:
- Type 2 diabetes
- Cardiovascular or peripheral vascular disease
- Pulmonary hypertension
- Increased blood lipid levels that are resistant to medication
- Recurrent or chronic skin ulcerations with infection
- Gastroesophageal reflux disease with aspiration
- Accelerated weight-bearing joint disease
The documentation also must contain a description of why the bariatric surgery is medically necessary.
The facility must be recognized as a Bariatric Surgery Center of Excellence® (BSCOE) by CMS as certified by the American Society for Metabolic and Bariatric Surgery, or must be accredited as a Level 1 bariatric surgery center as designated by the American College of Surgeons, or must be a children’s hospital with an Adolescent Bariatric Surgery Program.
The prior authorization request must include documentation to show that the patient has demonstrated his/her compliance with medical treatment. The patient also must have demonstrated at least 6 months of compliance with a physician directed, non-surgical weight-loss program that occurred with 12 months of the request date.
Other documentation must show:
- That the patient is psychologically mature and can cope with the post-surgical changes.
- That the patient and the parent/guardian (as applicable) understand and will follow the required changes in eating habits.
- That pre-operative nutritional and psychological services are available.
- How the patient will accept post-operative surgical, nutritional, and psychological services.
- To correct complications from bariatric surgery such as band malfunction, obstruction or stricture.
- To convert to a Roux-en-Y gastroenterostomy or to correct pouch failure.
Behavioral health services are not considered part of the bariatric surgery proper, but may be provided as part of the pre-operative or post-operative phase of bariatric surgery.