Providersshould Consultmasshealthregulationsat130cmr415.000 (Acuteinpatient Hospital Services)
GuidelinesforMedicalNecessityDeterminationForBariatricSurgery
These Guidelines for Medical Necessity Determination(Guidelines)identifythe clinical informationMassHealthneedstodeterminemedicalnecessityforbariatric surgery.These Guidelines arebased ongenerally acceptedstandards of practice,review of themedical literature, and federal and statepolicies andlaws applicabletoMedicaidprograms.
Providersshould consultMassHealthregulationsat130CMR415.000 (acuteinpatient hospital services),
433.000 (physicianservices), and450.000 (administrativeandbillingregulations),andSubchapter 6 ofthePhysicianManual for information aboutcoverage, limitations,serviceconditions, and otherprior-authorizationrequirements.Providers serving members enrolledina MassHealth-contractedmanagedcareorganization (MCO)should refertothe MCO’smedical policies forcovered services.
MassHealthreviews requestsfor prior authorization on thebasis ofmedicalnecessity.IfMassHealthapproves the request,payment is stillsubjecttoall generalconditions of MassHealth, including membereligibility,otherinsurance,andprogramrestrictions.
Section I.General Information
Bariatricsurgery(weight-losssurgery)consists of severalopenorlaparoscopicproceduresthatrevisethegastro-intestinal anatomytorestrict thesizeofthestomach and/or reduce absorption of nutrients.
Weight-losssurgeryis aneffective treatmentforsevere,medically complicated, and refractoryobesity withattendant risks that, insome rare cases,mayinclude death.Candidatesforthis surgery benefit frompre-operative and post-operativemultidisciplinary (medical,nutritional,behavioral/psychological,exercise/physiological)care.
MassHealthdeterminesthemedicalnecessityofbariatricsurgeryon an individual,case-by-case basis,inaccordance with130CMR 450.204,when neededtoeitheralleviate or correct medicalproblemscausedbysevere obesity. These guidelines apply toRoux-en-Ygastricbypasssurgery.Requests forotherformsofbariatric surgerywill requireexceptionalcircumstances and additional documentation,depending onthecase.
Section II:Clinical Guidelines
Clinical Coverage
MassHealthbasesits determination of medicalnecessity for bariatricsurgeryon a combination of clinicaldataandpresenceofindicators that wouldaffecttherelativerisks andbenefitsoftheprocedure(ifappropriate, includingpost-operativerecovery).
MG-BAS (11/14)1
These criteria include, butare notlimitedto,the following.
1.The surgerywill be performedundertheguidanceof a multidisciplinaryteam (including surgeon,physician,nutritionist, licensed qualifiedmental healthprofessional)particularlyexperienced in theperformance of bariatric surgeryand thepre- andpost-operativemanagement ofbariatric surgerypatients.
2.The surgerywillbeperformedin a facilityequipped toproperlycare forbariatricsurgerypatients.
3.The memberhas a bodymassindex(BMI)greater than40 ora BMI greaterthanor equalto 35withsignificant co-morbidconditions, for exampledegenerativejoint disease,circulatory and respiratoryinsufficiency, arteriosclerosis,hypertension,diabetes mellitus, obstructive sleepapnea,ordyslipidemia.
4.Thememberhasbeenseverely obesefor atleastfiveyears.
5.The providerhas ruledout metaboliccauses ofthemember’sobesity.
6.The memberis atleast18 years of age.
7.The member iswell informedoftherisksofsurgery.
8.The member isunder a physician’s supervision for the treatment ofobesity.
9.The memberhas satisfactorily completedthepre-operativecare plan.
10.There isno evidenceof activesubstanceabuse.
11.Any historyofbingeeating disorderhas beendocumentedand discussed.
Section III:Submitting Clinical Documentation
Requestsfor prior authorization forbariatricsurgery must be accompanied byclinicaldocumentationthatsupports the medical necessity for this procedure.
A.Documentationofmedical necessity must include allofthefollowing:
1.theprimarydiagnosisnameand theICD-CMcodefortheconditionrequiringsurgery;
2.thesecondarydiagnosisname(s) and ICD-CMcode(s)pertinent to any co-morbidconditions, ifpresent;
3.a descriptionof thepre- andpost- surgical treatment plans, includingthespecificprocedure(s) andCPTcodesforany plannedprocedures;
4.themost recent medicalevaluation, including a summaryofthe medicalhistoryandthe lastphysical exam including height,weight,patientand family history,personal andsocialhistory, aswell asmedicationspastandcurrent;
5.results fromdiagnosticand/orlaboratorytestspertinenttothediagnosisand, if present,co-morbidconditions;
6.riskfactorsand/or co-morbidconditions;
7.previous surgeries andhospitalizations;
8.initial andfollow- up nutritional evaluation(s) and the member’s ability toadheretonutritionalrestrictions;
9.initial andfollow-uppsychologicalevaluation(s)toassessthemember’sunderstandingof, andpsychologicalpreparednessfor,the surgery andthepost-surgicalrequirements;
10.documentationthat themember hasbeeninformedof therisksofthesurgery andofthe possiblelong- termcomplications;
11.a descriptionofa multidisciplinary aftercareplan;
12.pre-operative weight historydocumenting a serious attempt atweight lossduringthepre-surgicalperiod;
13.identification of social supports;
14historyof smoking, includingcurrentsmoking status; and
15.otherpertinent informationthat MassHealthmay request.
B.Clinicalinformationmustbe submitted by thesurgeon involvedinthe member’s bariatric care.Providersmust submitall informationpertinent tothediagnosis using theAutomatedPriorAuthorizationSystem(APAS) at bycompleting a MassHealth PriorAuthorizationRequestformandattaching pertinentdocumentation.
Select References
Blackburn G, Hu F,Harvey A,et al. Expert panelonweightlosssurgery. Betsy Lehman CenterforPatientSafety and Medical Error Reduction.Evidence-based recommendations forbest practices inweight losssurgery.ObesityResearch. 2005; 13: 203-305.
BrechnerR, Farris C, Harrison,Tillman,K, Salive C,Phurrough S. Summary of Evidence –BariatricSurgery.November 2004.CMS Report. Availableat: December9,2005.
AmericanCollegeofSurgeons. Committee onEmergingSurgicalTechnology andEducation. [ST-34].Recommendationsforfacilitiesperformingbariatricsurgery.Bulletin of the AmericanCollege of Surgeons.2000;85:Available at: Accessed December 5,2005.
Lee WJ, Huang MT,Yu PJ,Wang W,Chen TC. Laparoscopicvertical bandedgastroplasty andlaparoscopicgastricbypass: a comparison.Obes Surg.2004;14:626-634.
Buchwald H, AvidorY, Braunwald E,etal.Bariatric Surgery: A Systematic Review and Meta-Analysis.
JAMA.2004;292:1724-1737.
SjostromL,Lindroos A,PeltonenM,etal.Lifestyle,Diabetes, and Cardiovascular Risk Factors 10 YearsafterBariatricSurgery. New EnglJ Med. 2004:351:2683-2693.
Manterola C, Pineda V, VialM,Losada H, Munos S.Surgery forMorbid Obesity:SelectionofOperationBased on EvidencefromLiterature Review. Obes Surg.2005;15:106-113.
NIH. E.XavierPi-Sunyer, Chairof Expert Panel “ClinicalGuidelines on theIdentification, Evaluation, andTreatment of Overweight andObesity in Adults.The EvidenceReport.”NationalInstitute of HealthPublicationNo.98-4083.September, 1998.
GastrointestinalSurgeryforSevereObesity.NIH ConsensusStatementOnline1991Mar25-27.9(1):1-20.AccessedSeptember 2, 2005.
WeberM,Muller M, Bucher T, et al.Laparoscopic gastricbypass issuperior tolaparoscopic gastricbandingfortreatmentofmorbidobesity. Ann Surg. 2004;240:975-983.
BlueCross Blue Shield AssociationTechnology Assessment Program.Newertechniques in bariatricsurgeryfor morbid obesity: laparoscopicadjustable gastricbanding,biliopancreaticdiversion and long-limbgastricbypass.2005;20(5):1-72.
AetnaInsuranceCompany.Clinical PolicyBulletins.Obesity Surgery. 2005; No. 0157:1-22.
Inge T, Krebs N, GarciaV, et al.Bariatric surgery for severely overweightadolescents:concerns andrecommendations.Pediatrics.2004;114:217-223.
Snow V,BarryP, FittermanN, QaseemA, Weiss K, fortheclinicalEfficacyAssessmentSubcommitteeoftheAmericanCollege of Physicians.Pharmacologicand surgical managementofobesityinprimarycare: a clinicalpracticeguidelinefromtheAmericanCollege ofPhysicians.Ann InternMed.2005;142:525-531.
Societyof American GastrointestinalEndoscopic Surgeons (SAGES). Guidelinesfortheclinicalapplication oflaparoscopicbariatricsurgery.2003;Publication 0030;1-6.Availableat: December 5,2005.
Mason E. GastricSurgeryfor morbid obesity.SurgClinNAmerica.1992;72:501-513.
WatkinsBM, Montgomery KF, AhronieJH. Laparoscopicadjustablegastricbanding: early experiencein 400consecutivepatientsinthe USA.ObesSurg. 2005;15:82-87.
MognolP, Chosidow D, Marmuse JP. Laparoscopic gastric bypass versus laparoscopicadjustablegastricbanding inthesuperobese:acompartivestudy of 290 patients. ObesSurg.2005;15:76-81.
Sogg S,MoriDAL.TheBostoninterviewforgastricbypass:determiningthepsychologicalsuitability of surgicalcandidates. ObesSurg. 2004;14:370-380.
ChevallierJM,ZinzindohoueF,DouardR,etal.Complicationsafterlaparoscopicadjustablegastricbanding formorbidobesity: experience with 1,000 patients over 7 years.Obes Surg. 2004;14:407-414.
TheseGuidelinesarebased onreviewof themedicalliterature andcurrent practice in bariatric surgicalprocedures.MassHealth reservestherightto reviewandupdatethecontentsof thisGuidelineandcited referencesasnewclinicalevidenceand medicaltechnologyemerge.
This document was preparedfor medical professionalsto assist theminsubmittingdocumentationsupportingthemedicalnecessity of proposedtreatment.Somelanguage usedin thiscommunication maybe unfamiliarto otherreaders; inthiscase,contactyour healthcareprovider for guidanceor explanation.
Policy EffectiveDate:
April 1,2006
Approved by:
, MedicalDirector
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