PA Lookup

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

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

• Trillium iTransact Portal

Resources

• Clinical Coverage Policy No: 1A-15
• Records Management and Documentation Manual

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.

Additional Service Specifics

As a bariatric surgical procedure, this procedure code is only covered for revision of lap banding when both the gastric band and subcutaneous port components are to be removed and replaced and ALL criteria are met

How to Submit

Please submit your request to Trillium Health Resources

• Trillium iTransact Portal

Resources

• Clinical Coverage Policy No: 1A-15
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

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

• Trillium iTransact Portal

Resources

• Clinical Coverage Policy No: 1A-15
• Records Management and Documentation Manual

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.

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

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-15
• Records Management and Documentation Manual

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.

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

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-15
• Records Management and Documentation Manual

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.

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

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-15
• Records Management and Documentation Manual

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.

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

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-15
• Records Management and Documentation Manual

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

• Trillium iTransact Portal

Resources

• Clinical Coverage Policy No: 1A-15
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required