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WELLCARE OF OHIO-HMO
MEDICAID
MEDICAL POLICY:
WellCare considers Bariatric Surgery for the treatment of morbid obesity medically
necessary when ALL the following criteria are met:
 Presence of morbid obesity has persisted for at least 5 years, defined as either:
o BMI exceeding 40; or
o BMI greater than 35 in conjunction with ANY of the following severe comorbid conditions:
 Coronary Heart Disease
 Type 2 Diabetes Mellitus
 Clinically significant Obstructive Sleep Apnea (i.e. patient meets
the criteria for treatment of obstructive sleep apnea.)
 Medically Refractory Hypertension (blood pressure greater than
140 mmHg systolic and/or 90mmHg diastolic despite optimal
medical management)
 Patient has completed growth (18 years of age or documentation of completion of
bone growth).
 The member must participate in an organized multidisciplinary surgical
preparatory regimen coordinated by a qualified bariatric surgeon of at least 3
months duration in order to improve surgical outcomes, reduce the potential for
surgical complications, and establish the member’s ability to comply with postoperative medical care and dietary restrictions.
 Patient has participated in a physician-supervised nutrition and exercise program
(including a low calorie diet, increased physical activity, and behavioral
modifications). This physician-supervised nutrition and exercise program must
meet ALL of the following criteria:
o Participation in nutrition and exercise program must be supervised and
monitored by a physician; AND
o Nutrition and exercise program must be 6 months or longer in duration;
AND
o Nutrition and exercise program must occur with in the 2 years prior to
surgery
o Participation in physician-supervised nutrition and exercise program must
be documented in the medical record by an attending physician who does
not perform bariatric surgery.
o Programs such as Weight Watchers, jenny Craig, OptiFast are acceptable
alternatives if done in conjunction with physician supervision and detailed
documentation of participation is available for review. However,
physician-supervised programs consisting exclusively of pharmacological
management are not sufficient to meet this requirement.

Mental health evaluation by a psychiatrist or psychologist to determine any
contraindications as listed below, mental competency and understanding of the
nature, extent and possible complications of the surgery and ability to sustain
dietary behavioral modifications needed to ensure a successful outcome of
surgery. Contraindicated diagnoses are:
o Active drug abuse
o Active suicidal ideation
o Borderline personality disorder
o Schizophrenia
o Psychotic disorder
o Uncontrolled depression
o Defined non-compliance with previous medical care
REVISIONS:
A complication of the original procedure, such as obstruction or stricture or failure of the
primary procedure due to dilation of the gastric pouch (if the primary procedure was
successful in inducing weight loss prior to the pouch dilation).