PA Lookup
If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Gastrotomy; with esophageal dilation and insertion of permanent intraluminal tube (eg, Celestin or Mousseaux-Barbin)
How to Submit
N/A - No authorization is required
Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedt type operation)
How to Submit
N/A - No authorization is required
Biopsy of stomach, by laparotomy
How to Submit
N/A - No authorization is required
Excision, local; ulcer or benign tumor of stomach
How to Submit
N/A - No authorization is required
Excision, local; malignant tumor of stomach
How to Submit
N/A - No authorization is required
Gastrectomy, total; with esophagoenterostomy
How to Submit
N/A - No authorization is required
Gastrectomy, total; with Roux-en-Y reconstruction
How to Submit
N/A - No authorization is required
Gastrectomy, total; with formation of intestinal pouch, any type
How to Submit
N/A - No authorization is required
Gastrectomy, partial, distal; with gastroduodenostomy
How to Submit
N/A - No authorization is required
Gastrectomy, partial, distal; with gastrojejunostomy
How to Submit
N/A - No authorization is required
Gastrectomy, partial, distal; with Roux-en-Y reconstruction
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
Gastrectomy, partial, distal; with formation of intestinal pouch
How to Submit
N/A - No authorization is required
Vagotomy when performed with partial distal gastrectomy (List separately in addition to code[s] for primary procedure)
How to Submit
N/A - No authorization is required
Vagotomy including pyloroplasty, with or without gastrostomy; truncal or selective
How to Submit
N/A - No authorization is required
Vagotomy including pyloroplasty, with or without gastrostomy; parietal cell (highly selective)
How to Submit
N/A - No authorization is required
Surgery for Clinically Clinical Severe or Morbid Obesity
Surgery for clinically severe or morbid obesity is performed for long-term surgical weight loss management. This may result in improvement of the co-morbidities of obesity. The goal of the surgery is to reduce the morbidity associated with obesity, and to improve metabolic and organ function. Surgery for clinically severe or morbid obesity (referred to as a bariatric surgical procedure for the purpose of this policy) falls into two general categories: a. gastric-restrictive procedures which create a small gastric pouch resulting in weight loss by producing early satiety and thus decreasing dietary intake because the amount of food that can be eaten at one time is greatly reduced; and b. malabsorptive procedures, which produce weight loss due to malabsorption by altering the normal transit of ingested food through the intestinal tract. Following a malabsorption procedure, the number of calories, fats and nutrients that can be absorbed during digestion is reduced. Some bariatric surgical procedures have both a restrictive and a malabsorptive component.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
Note: A letter from the surgeon stating that all criteria have been met is not sufficient documentation.
The approval does not transfer to a different provider or allow for change in bariatric surgical procedure. If either occurs, a new request must be submitted, and all policy requirements met for approval.
In addition to the general requirements, the provider(s) shall submit a description of the type of bariatric surgical procedure planned.
The beneficiary shall meet all policy requirements, and the provider shall obtain prior approval before performing a bariatric surgical procedure, if the primary insurance does not cover the procedure.
A provider’s summary letter alone is not considered a health record. Encounter notes must document the following:
- a. beneficiary’s name on each page;
- b. date of service;
- c. exclusive purpose for pre-surgical bariatric evaluation or treatment,
assessments, and findings;
- d. individualized intervention; and
- e. beneficiary’s response to the treatment plan.
All documentation must be completed timely to date of service. If a late entry is unavoidable, it must be identified as such, signed, and dated with referencing to the date and time relating back to the date of service. Illegible documentation is not processed for a prior approval request.
The facility’s documentation of their Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accreditation must be submitted with each prior approval request beginning November 1, 2023.
Limits
The beneficiary must have met all bariatric surgery criteria for the past 12 calendar months prior to the request for surgery.
Required dietician or nutritionist comprehensive evaluation must occur within the past six calendar months before the surgery request and must be face-to-face, not in a group setting.
Required psychological evaluation must document the past six calendar months.
Medical treatment for obesity must have been unsuccessful for the past 12 calendar months prior to the request, including at least three calendar months of treatment provided or supervised by a medical provider.
Monthly encounter notes are required during the supervised treatment period.
Exclusions
Medicaid shall not cover the following:
- 1. Jejunoileal bypass;
- 2. Biliopancreatic diversion with or without duodenal switch for a
beneficiary with a BMI < 50 kg/m2;
- 3. Gastric wrapping;
- 4. Adjustable gastric banding for a beneficiary with a BMI > 50 kg/m2;
- 5. Jejunocolostomy;
- 6. Mini-gastric bypass;
- 7. Open sleeve gastrectomy;
- 8. Gastric bypass with roux limb greater than 150 cm for a beneficiary with
a BMI less than 55 kg/m2.;
- 9. Bariatric surgical procedures for a beneficiary with a BMI less than 35
kg/m2;
- 10. Gastric electrical stimulation;
- 11. Revision of a primary bariatric surgical procedure when the beneficiary
does not meet the criteria in Subsection 3.2.4;
- 12. Staged procedures; or
- 13. Cosmetic surgery: Weight loss following bariatric surgical procedures
can result in skin and fat folds in locations such as the medial upper arms, lower abdominal area, and medial thighs. Surgical removal of this skin and fat for solely cosmetic purposes is not covered.
Medicaid shall not cover a bariatric surgical procedure or a beneficiary who is:
- 1. a preadolescent child,
- 2. a pregnant or breast-feeding adult or adolescent
- 3. planning to become pregnant within two years of surgery; or
- 4. not demonstrating mastery of the principles of healthy dietary and
activity habits.
The following conditions are contraindications to a bariatric surgical procedure, and approval cannot be granted until there is health record documentation that the conditions are resolved:
- 1. untreated major depression or psychosis;
- 2. binge-eating disorders; or
- 3. current drug and alcohol abuse.
Age Group Details
18 years of age and older; beneficiaries under 18 are considered on a case-by-case basis under EPSDT
Place of Service
Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Centers.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Surgery for Clinically Clinical Severe or Morbid Obesity
Surgery for clinically severe or morbid obesity is performed for long-term surgical weight loss management. This may result in improvement of the co-morbidities of obesity. The goal of the surgery is to reduce the morbidity associated with obesity, and to improve metabolic and organ function. Surgery for clinically severe or morbid obesity (referred to as a bariatric surgical procedure for the purpose of this policy) falls into two general categories: a. gastric-restrictive procedures which create a small gastric pouch resulting in weight loss by producing early satiety and thus decreasing dietary intake because the amount of food that can be eaten at one time is greatly reduced; and b. malabsorptive procedures, which produce weight loss due to malabsorption by altering the normal transit of ingested food through the intestinal tract. Following a malabsorption procedure, the number of calories, fats and nutrients that can be absorbed during digestion is reduced. Some bariatric surgical procedures have both a restrictive and a malabsorptive component.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
Note: A letter from the surgeon stating that all criteria have been met is not sufficient documentation.
The approval does not transfer to a different provider or allow for change in bariatric surgical procedure. If either occurs, a new request must be submitted, and all policy requirements met for approval.
In addition to the general requirements, the provider(s) shall submit a description of the type of bariatric surgical procedure planned.
The beneficiary shall meet all policy requirements, and the provider shall obtain prior approval before performing a bariatric surgical procedure, if the primary insurance does not cover the procedure.
A provider’s summary letter alone is not considered a health record. Encounter notes must document the following:
- a. beneficiary’s name on each page;
- b. date of service;
- c. exclusive purpose for pre-surgical bariatric evaluation or treatment,
assessments, and findings;
- d. individualized intervention; and
- e. beneficiary’s response to the treatment plan.
All documentation must be completed timely to date of service. If a late entry is unavoidable, it must be identified as such, signed, and dated with referencing to the date and time relating back to the date of service. Illegible documentation is not processed for a prior approval request.
The facility’s documentation of their Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accreditation must be submitted with each prior approval request beginning November 1, 2023.
Limits
The beneficiary must have met all bariatric surgery criteria for the past 12 calendar months prior to the request for surgery.
Required dietician or nutritionist comprehensive evaluation must occur within the past six calendar months before the surgery request and must be face-to-face, not in a group setting.
Required psychological evaluation must document the past six calendar months.
Medical treatment for obesity must have been unsuccessful for the past 12 calendar months prior to the request, including at least three calendar months of treatment provided or supervised by a medical provider.
Monthly encounter notes are required during the supervised treatment period.
Exclusions
Medicaid shall not cover the following:
- 1. Jejunoileal bypass;
- 2. Biliopancreatic diversion with or without duodenal switch for a
beneficiary with a BMI < 50 kg/m2;
- 3. Gastric wrapping;
- 4. Adjustable gastric banding for a beneficiary with a BMI > 50 kg/m2;
- 5. Jejunocolostomy;
- 6. Mini-gastric bypass;
- 7. Open sleeve gastrectomy;
- 8. Gastric bypass with roux limb greater than 150 cm for a beneficiary with
a BMI less than 55 kg/m2.;
- 9. Bariatric surgical procedures for a beneficiary with a BMI less than 35
kg/m2;
- 10. Gastric electrical stimulation;
- 11. Revision of a primary bariatric surgical procedure when the beneficiary
does not meet the criteria in Subsection 3.2.4;
- 12. Staged procedures; or
- 13. Cosmetic surgery: Weight loss following bariatric surgical procedures
can result in skin and fat folds in locations such as the medial upper arms, lower abdominal area, and medial thighs. Surgical removal of this skin and fat for solely cosmetic purposes is not covered.
Medicaid shall not cover a bariatric surgical procedure or a beneficiary who is:
- 1. a preadolescent child,
- 2. a pregnant or breast-feeding adult or adolescent
- 3. planning to become pregnant within two years of surgery; or
- 4. not demonstrating mastery of the principles of healthy dietary and
activity habits.
The following conditions are contraindications to a bariatric surgical procedure, and approval cannot be granted until there is health record documentation that the conditions are resolved:
- 1. untreated major depression or psychosis;
- 2. binge-eating disorders; or
- 3. current drug and alcohol abuse.
Age Group Details
18 years of age and older; beneficiaries under 18 are considered on a case-by-case basis under EPSDT
Place of Service
Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Centers.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum
How to Submit
N/A - No authorization is required
Laparoscopy, surgical; transection of vagus nerves, truncal
How to Submit
N/A - No authorization is required
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.