Effective immediately, BadgerCare Plus has updated criteria for coverage of all bariatric procedures. Bariatric surgery is covered under the criteria listed in this BadgerCare Plus Update for both the BadgerCare Plus Standard Plan and the Benchmark Plan. This Update replaces guidelines given in the January 2005 Update (2005-01), titled “Updated Prior Authorization Criteria for Bariatric Surgery,” and the December 2005 Update (2005-75), titled “Bariatric Surgery Clarification and Reminders.”

Comorbidities

Providers are required to submit with a prior authorization (PA) request clinically documented evidence that a continued comorbid clinical status will lead to serious impairment of the member's health, and treatment of the comorbid condition for a minimum of three months has not improved the health risks and impairments.

Such comorbid conditions undergoing current appropriate therapy trials would include, for example, but not be restricted to, congestive heart failure, recurrent venous thrombosis with or without pulmonary emboli, uncontrolled diabetes mellitus or demonstrated coronary artery disease with hemodynamically significant arteriolar occlusion leading to documented myocardial dysfunction.

Facility Requirements

Effective immediately, BadgerCare Plus requires all bariatric surgery procedures to be performed at a facility that is Medicaid certified and meets one of the following requirements:

• The center has been certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center.
• The facility has been certified by the American Society for Bariatric Surgery (ASBS) as a Bariatric Surgery Center of Excellence.

Claims for bariatric services from a hospital that does not meet the above criteria will be denied.

Refer to Attachment 1 of this Update for a current list of approved facilities. As this list may change at any time, providers are advised to check for revisions to the list at www.cms.hhs.gov/MedicareApprovedFacilitie/BSF/list.asp.

Laparoscopic Adjustable Gastric Banding

Effective immediately, BadgerCare Plus covers laparoscopic adjustable gastric banding (LAGB) (Current Procedural Terminology [CPT] procedure codes 43770-43774). Coverage of LAGB is subject to the same approval criteria as other covered bariatric procedures.

Prior Authorization Approval Criteria

All BadgerCare Plus-covered bariatric surgery procedures (CPT procedure codes 43644-43645, 43659, 43770-43774, 43842-43843, 43846-43848) require PA. As a reminder, PA requests must be submitted by physicians, and claims must be submitted by facilities. If a PA is not on file when the claim is submitted, the claim will be denied. The approval criteria for PA requests for BadgerCare Plus-covered bariatric surgery procedures include all of the following:

• The member must have one of the following:
• A body mass index (BMI) of 40 or greater (include clinical documentation that a continued morbidly obese status will lead to serious impairment of the member’s health because of comorbid conditions that cannot be optimally corrected with current therapy) with a demonstrated and documented trial of a minimum of three months.
1. Such comorbid conditions undergoing current appropriate therapy would include, but not be limited to, congestive heart failure, recurrent venous thrombosis with or without pulmonary emboli, uncontrolled diabetes mellitus, or demonstrated coronary artery disease with hemodynamically significant arteriolar occlusion leading to myocardial dysfunction.
2. A three-month period of a physician-supervised program including dietary counseling, behavioral modification, and supervised exercise, plus a psychiatric evaluation prior to surgery would be required for those members whose clinical status is stable. This would provide time to stabilize the member’s current clinical status, and educate the member through behavioral modification related to eating habits, appropriate exercise, and psychological support to assure the greatest success with weight control after surgery.
• A BMI between 35 and 39 with documented high-risk comorbid medical conditions that have not responded to medical management and are a threat to life, such as, but not limited to clinically significant obstructive sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy, coronary heart disease, or medically refractory hypertension.
• Documentation that the member has attempted weight loss in the past without successful long-term weight reduction. These attempts may include, but are not limited to, diet restrictions or supplements, behavior modification, physician-supervised weight loss plans, physical activity programs, commercial or professional programs, and pharmacological therapy.
• For all members who are stable without documented life-threatening comorbidities, documentation must be presented that the member has clinically documented evidence of a minimum of six months of demonstrated adherence to a physician-supervised weight management program including at least three consecutive months of participation in a weight management program prior to the date of surgery in order to improve surgical outcomes, reduce the potential for surgical complications and establish the member’s ability to comply with post-operative medical care and dietary restrictions. A physician’s summary letter is not sufficient documentation. Documentation must include assessment of the member's participation and progress throughout the course of the program. The member must also agree to attend a medically supervised post-operative weight management program for a minimum of six months post-surgery for the purpose of ongoing dietary, physical activity, behavioral/psychological, and medical education monitoring.
• The member should receive a preoperative evaluation by an experienced and knowledgeable multidisciplinary bariatric treatment team composed of health care providers with medical, nutritional, and psychological experience. This evaluation must include, at a minimum:
• A complete history and physical examination, specifically evaluating for obesity-related comorbidities that would require preoperative management.
• Evaluation for any correctable endocrinopathy that might contribute to obesity.
• Psychological or psychiatric evaluation and clearance to determine the stability of the member in terms of tolerating the operative procedure and postoperative sequelae, as well as the likelihood of the member participating in an ongoing weight management program following surgery.
• Members receiving active treatment for a psychiatric disorder must receive evaluation by their treatment provider prior to bariatric surgery and be cleared for bariatric surgery.
• Dietary assessment and counseling.
• The member must be 18 years of age or older and have completed growth.
• The member must have a BMI of 50 or less for approval of LAGB (43770-43774).

Information Regarding Managed Care

This Update contains fee-for-service policy and applies to services members receive on a fee-for-service basis only. For managed care policy, contact the appropriate managed care organization. BadgerCare Plus HMOs are required to provide at least the same benefits as those provided under fee-for-service arrangements.

Attachment — Level 1 Bariatric Surgery Centers and Centers of Excellence