Priority Health Weight Loss Surgery – How to Avoid a Denial

In order to be approved by Priority Health for bariatric surgery in the United States, you must meet the following criteria:

1. Over 18 years of age and the surgery must be performed by a surgeon who is a regular member in good standing of the American Society for Metabolic and Bariatric Surgery (ASMBS)
2. Diagnosis of Morbid obesity, defined as
• a Body Mass Index (BMI) greater than 50 with no co-morbidity or participation in medical weight management program required
• a Body Mass Index (BMI) greater than 40, a co-morbidity is not required, however, participation in medical weight management program is

Or

• a BMI 35 – 39.9 AND one of the following
• Symptomatic sleep apnea requiring treatment
• Significant cardiac disease (e.g. ASHD, RVH or LVH)
• Hypertension on one or more medications
• Hyperlipidemia on therapy
• Diabetes with HgbA1 C greater than 7.0 on one or more medications or insulin

Use this BMI Calculator to check your body mass index…

3. Prior approval must be obtained for Bariatric Surgery
4. A pre-operative care and evaluation must occur in which all of the following must be met:
• Complete medical evaluation by PCP or other physician
• Evidence that all other alternatives have been discussed with and offered to patient, and that all reasonable non – surgical options have been attempted
• Documentation of active participation in and compliance with a medical weight management program, when applicable, provided by a credentialed physician with a declared interest in the management of obesity, the member’s primary care physician (PCP) or other managing physician as outlined in the Medical Management of Obesity policy. The medical weight management program must include all of the following:
• Documentation of active participation and compliance with a medical weight management program for a minimum continuous duration of * 6 months with at least 6 office visits including both a diet and exercise component and in which the obesity and weight – related conditions (i.e. diabetes, hypertension and hyperlipidemia) are being addressed
• NOTE: this only applies for individuals with a body mass index below 50
• Priority Health Medicaid requires compliance with a medical weight management for a minimum continuous duration of 12 months and at least 12 office visits
• Thorough progress notes and records that include the following regarding the obesity problem at each visit:
• An actual measured weight and calculated BMI
• The patient’s history
• An actual measured weight and calculated BMI
• The physical findings
• The physician’s assessment
• The physician’s treatment recommendation(s)/plan(s)
• The medical weight management program must be completed within two years of the request for surgery. All documentation in #3 above should be submitted with the Bariatric Surgery prior authorization form. The BMI recorded on the prior authorization form should be based upon measurement of height and weight within one month of requesting the evaluation

Revision Requirements

Coverage is limited to one bariatric surgery per lifetime regardless of insurance carrier or other means of payment at the time of surgery, unless Medically/Clinically Necessary to correct or reverse complications from a previous bariatric procedure.

Priority Health Contact Information and Full Medical Policy on Bariatric Surgery

• By Phone: 800.942.0954
• Contact Priority Health
• Full Bariatric Surgery Medical Policy for Priority Health