TMPPM 2011 > Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook > Physician > Services/Benefits, Limitations, and Prior Authorization > Bariatric Surgery > Prior Authorization for Bariatric Surgery

8.2.8.1 Prior Authorization for Bariatric Surgery

All clients must meet the criteria outlined below.

The same contraindicates exist for bariatric surgery as for any other elective abdominal surgery. Documentation provided for prior authorization must attest that none of the following additional contraindications exist:

•Endocrine cause for obesity, inflammatory bowel disease, chronic pancreatitis, cirrhosis, portal hypertension, or abnormalities of the gastrointestinal tract

•Chronic, long-term steroid treatment

•Pregnant, or plans to become pregnant within 18 months

•Noncompliance with medical treatment

•Significant psychological disorders that would be exacerbated or interfere with the long-term management of the client after the operation

•Active malignancy

Note: Clients with known serious mental illness must be assessed prior to surgery to ascertain that their illness is not a contraindication to surgery. Clients must be referred for appropriate professional evaluation any time the presence of serious mental illness is suspected.

Bariatric surgery may be prior authorized when the client meets all of the following criteria:

•The client is a female at least 13 years of age and menstruating, or a male at least 15 years of age, who has reached a Tanner stage IV plus 95 percent of adult height based on bone age.

•Clients who are birth through 20 years of age must have a body mass index (BMI) of greater than or equal to 40 kg/m2.

•Clients who are 21 years of age and older must have a BMI of greater than or equal to 35 kg/m2.

•The client, regardless of age, has at least one major or two lesser comorbid conditions as follows:

•Major comorbid conditions include:

•Obesity-associated hypoventilation

•Obstructive sleep apnea

•Congestive heart failure

•Uncontrolled malignant hypertension resistant to pharmacotherapy

•Pseudotumor cerebri

•Lesser comorbid conditions include:

•Adult onset (Type II) diabetes (with or without complications)

•Cardiovascular or peripheral vascular disease

•Increased blood lipid levels resistant to pharmacotherapy

•Recurrent or chronic skin ulcerations with infection

•Pulmonary hypertension

•Accelerated weight-bearing joint disease

•Gastroesophageal reflux disease with aspiration

Documentation submitted for prior authorization must include all of the following:

•Summary of treatment provided for the client's co-morbid conditions.

•Description of how the client's response to standard treatment measures is unsatisfactory.

•Description of why the bariatric surgery is medically necessary in the context of current treatment and the medically reasonable alternatives that are available.

•The name of the facility in Texas in which the procedure will be performed. (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.)

•Documentation that the client has demonstrated compliance with medical treatment. (The client must also have demonstrated at least 6 months of compliance with a physician-directed, nonsurgical weight-loss program within 12 months of the request date.)

•Documentation of the following:

•The client is psychologically mature and able to cope with the postsurgical changes.

•The client and the parent/guardian (as applicable) understand and will support the changes in eating habits that must accompany the surgery and the extensive postoperative follow-up.

•Adequate preoperative nutritional and psychological services.

•How the client will receive postoperative surgical, nutritional, and psychological services.

Repeat bariatric surgery may be considered medically necessary in either of the following circumstances:

•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 in an otherwise compliant client when the initial bariatric surgery met medical necessity criteria.

Note: Conversion to a Roux-en-Y gastroenterostomy may be considered medically necessary for clients who have not had adequate success (defined as a loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure, and the client has been compliant with a prescribed nutrition and exercise program following the procedure.

Providers may fax or mail prior authorization requests for bariatric surgery services for clients who are 20 years of age and younger to the TMHP Comprehensive Care Program (CCP) Department. Prior authorization requests for clients who are 21 years of age and older may be faxed or mailed to the TMHP Special Medical Prior Authorization Department.

Clients may be eligible under Texas Medicaid or CCP for separate reimbursement for nutritional and psychological assessment and counseling associated with bariatric surgery.

Behavioral health services provided as part of the preoperative or postoperative phase of bariatric surgery are subject to behavioral health guidelines, and are not considered part of the bariatric surgery.

Refer to: Subsection 7.14, "Psychiatric Services for Hospitals," in Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbook) for information about behavioral health services.

Procedure code 43644 will be denied when billed by the same provider with the same date of service as procedure code 43645 or 43846.

Procedure code 43848 will be denied when billed by the same provider with the same date of service as procedure codes 43770, 43771, 43772, 43773, 43774, 43842, 43843, 43846, or 43847.

Procedure code 43772 will be denied when billed by the same provider with the same date of service as procedure code 43773 or 43774.

Procedure code 43888 will be denied when billed by the same provider with the same date of service as procedure code 43774.

Procedure code 43645 will be denied when billed by the same provider with the same date of service as procedure code 43847.

Procedure code 43846 will be denied when billed by the same provider with the same date of service as procedure code 43847.

Procedure code 43887 will be denied when billed by the same provider with the same date of service as procedure code 43888.

The following procedure codes will be denied if billed on the same date of service by the same provider as procedure code 43845: