Download insurance authorization requirements

PHOENIX BARIATRIC CENTER, PLC
3805 E Bell Rd, Suite 5300
Phoenix, AZ 85032
Ph 602 422 9690 Fax 602 422 9680
Kurt W. Sprunger, MD, FACS
INSURANCE AUTHORIZATION REQUIREMENTS
ALL PATIENTS
Age 18 or older
Phoenix Bariatric Center Seminar Attendance Certificate
PCP Bariatric Referral Letter (Letter of Medical Necessity)
Initial Consultation with Bariatric Surgeon
INSURANCE COMPANY REQUIREMENT SUMMARIES
ABRAZO ADVANTAGE (MEDICARE)
BMI 35 or greater with one comorbidity
Documentation of Severe/ Morbid Obesity for at least the past 3 years (2-3 office notes per year)
Dietician or Nutritionist Consult
Psychology Consult (MMPI required)
Documentation of Medically Supervised Weight Loss by a physician (may be bariatric surgeon)
for 6 consecutive months within the past 2 years
Failed 3 month trial of at least one obesity drug
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
AETNA
BMI 40 or greater, or BMI 35-39.9 with specific comorbidities (See AETNA specific page)
Documentation of Severe/ Morbid Obesity for at least the past 2 years
Dietitian or Nutritionist Consult
Completion of 6 month Physician-supervised nutrition and exercise program or 3 month Multidisciplinary surgical preparatory regimen (See AETNA specific page)
Psychology clearance ONLY for patients who have a history of severe psychiatric disturbance
(schizophrenia, borderline personality disorder, suicidal ideation, depression) or who are
currently under the care of a psychologist or psychiatrist or who are on psychotropic/ antidepressant medications
Medical Clearances are discretionary
Covered procedures: Gastric Bypass, Adjustable Gastric Band, Sleeve Gastrectomy
COE not required
ANTHEM BCBS (Includes: Blue Cross KY, WI, OH, CA, GA, MO, NY Empire)
BMI 40 or greater, or BMI 35-39.9 with a comorbidity (See ANTHEM BCBS specific page)
Dietitian or Nutritionist Consult
Psychology consult
Specific Medically Supervised Weight Loss requirement not stipulated
Medical Clearances are discretionary
Covered procedures: Gastric Bypass, Adjustable Gastric Band, Sleeve Gastrectomy
COE required
APIPA (ARIZONA PHYSICIANS IPA) / UNITED HEALTHCARE COMMUNITY PLAN
BMI 40 or greater, or BMI 35-39.9 with a comorbidities
Dietician or Nutritionist Consult
Psychology Consult (MMPI required)
Documentation of Medically Supervised Weight Loss 6 consecutive within the past two years
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
ARIZONA FOUNDATION for MEDICAL CARE (AFMC)
BMI 40 or greater with “life-threatening” comorbid condition
Documentation of Severe Obesity for 5 years (must include documented weight history, 2-3 office
notes per year)
Dietician or Nutritionist Consult
Psychology Consult (MMPI required)
Documentation of Medically Supervised Weight Loss for 6 consecutive months within the past 2
years
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
BLUE CROSS BLUE SHIELD of ARIZONA (BCBS AZ)
BMI 40 or greater, or BMI 35-39.9 with comorbidities (See BCBS AZ specific page)
Documentation of Severe/ Morbid Obesity for past 5 years
Dietitian or Nutritionist Consult
Psychology consult
Documentation of Medically Supervised Weight Loss at least 8 weeks within past 12 months (See
BCBS AZ specific page)
Medical Clearances are discretionary
Covered procedures: Gastric Bypass, Adjustable Gastric Band, Sleeve Gastrectomy
Requires Blue Distinction Center
CIGNA
BMI 40 or greater, or BMI 35-39.9 with at least one comorbidity
Dietitian or Nutritionist Consult
Psychology consult
Documentation of Medically Supervised Weight Loss for 3 consecutive months by PCP or
Dietitian
Medical Clearances are discretionary
Covered procedures: Gastric Bypass, Adjustable Gastric Band, Sleeve Gastrectomy
COE not required
GREAT WEST HEALTHCARE (Requirements are the same as CIGNA)
BMI 40 or greater, or BMI 35-39.9 with at least one comorbidity
Dietitian or Nutritionist Consult
Psychology consult
Documentation of Medically Supervised Weight Loss for 3 consecutive months by PCP or
Dietitian
Medical Clearances are discretionary
Covered procedures: Gastric Bypass, Adjustable Gastric Band, Sleeve Gastrectomy
COE not required
HEALTH CHOICE
BMI 35 or greater with one comorbidity
Documentation of Severe Obesity for 5 years (documented weight history, 2-3 office notes per
year)
Psychology Consult (MMPI required)
Documentation of Medically Supervised Weight Loss for 12 consecutive months within last 2
years, including food diary - total daily calorie intake, total daily fat grams, food groups used,
conditions where overeating occurs; and physical activity log - frequency, intensity and duration
of exercise
Documentation from PCP of smoking cessation for 6 months
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
HEALTH NET of ARIZONA
BMI 35 or greater with one comorbidity
Documentation of Severe Obesity for 5 years (documented weight history, 2-3 office notes per
year)
Dietician or Nutritionist Consult
Psychology Consult (MMPI required)
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
HEALTH NET of ARIZONA (MEDICARE)
BMI 35 or greater with one comorbidity
Documentation of Severe Obesity for 5 years (documented weight history, 2-3 office notes per
year)
Dietician or Nutritionist Consult
Psychology Consult (MMPI required)
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
HUMANA
BMI 35 or greater with one comorbidity
Documentation of Severe Obesity for 2 years (documented weight history, 2-3 office notes per
year)
Psychology Consult (MMPI required)
Documentation of Medically Supervised Weight Loss for 6 consecutive months within the past 2
years
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
HUMANA (MEDICARE)
BMI 35 or greater with one comorbidity
Documentation of Severe Obesity for 2 years (documented weight history, 2-3 office notes per
year)
Psychology Consult (MMPI required)
Documentation of Medically Supervised Weight Loss for 6 consecutive months within the past 2
years
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
MARICOPA INTEGRATED HEALTH PLAN
BMI 35 or greater with one comorbidity
Documentation of Severe Obesity for 5 years (documented weight history, 2-3 office notes per
year)
Dietician or Nutritionist Consult
Psychology Consult (MMPI required)
Documentation of Medically Supervised Weight Loss for 6 consecutive months within the past 2
years
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
MEDICARE
BMI 35 or greater with one comorbidity
Documentation that patient has been “previously unsuccessful with medical treatment for
obesity.”
Psychology consult
Cardiac and Pulmonary Clearances
Covered procedures: Gastric Bypass, Adjustable Gastric Band, Sleeve Gastrectomy
COE required
MERCY CARE
BMI 35 or greater with one comorbidity
Documentation of Severe Obesity for 2 years (documented weight history, 2-3 office notes per
year)
Dietician or Nutritionist Consult
Psychology Consult (MMPI required) preferred within last 90 days
Documentation of Medically Supervised Weight Loss by PCP for 6 consecutive months within the
past year (including daily food log or food journal for 6 months)
Normal TSH within last 6 months
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
Cardiac and Pulmonary must be approved by Mercy Care Plan; preferred within last 90 days
MERITAIN HEALTH
BMI 40 or greater, or BMI 35-39.9 with comorbidities
Dietitian or Nutritionist Consult
Psychology consult
Documentation of Severe/ Morbid Obesity for past 5 years (perhaps should be stated in LOMN
and H&P)
Documentation of Medically Supervised Weight Loss for 6 consecutive months or two periods of
3 consecutive months each within the past 2 years
Cardiac clearance
Other Clearances are discretionary
Covered procedures: Gastric Bypass, Adjustable Gastric Band
PACIFICARE of ARIZONA
BMI 35 or greater with one comorbidity
Documentation of Severe/ Morbid Obesity for past one year (documented weight history; 2-3
office notes per year)
Dietician or Nutritionist Consult
Psychology Consult (MMPI required)
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
PHOENIX HEALTH PLAN (PHP)
BMI 35 or greater with one comorbidity
Documentation of Severe/ Morbid Obesity for at least the past 3 years (2-3 office notes per year)
Dietician or Nutritionist Consult
Psychology Consult (MMPI required)
Documentation of Medically Supervised Weight Loss by a physician (may be bariatric surgeon)
for 6 consecutive months within the past 2 years
Failed 3 month trial of at least one obesity drug
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
SECURE HORIZONS / PACIFICARE of ARIZONA (MEDICARE)
BMI 35 or greater with one comorbidity
Documentation of Severe/ Morbid Obesity for past one year (documented weight history; 2-3
office notes per year)
Dietician or Nutritionist Consult
Psychology Consult (MMPI required)
Cardiac and Pulmonary Consults mandatory if age 50 or greater or BMI 50 or greater
TRICARE
BMI 40 or greater, or BMI 35-39.9 with one comorbidity
Dietitian or Nutritionist Consult not stipulated
Psychology consult not stipulated
Documentation failure of non-surgical treatments for obesity (See TRICARE specific page)
Medical Clearances are discretionary
Covered procedures: Gastric Bypass, Adjustable Gastric Band; NOT Sleeve Gastrectomy
Required to have surgery at an approved VA facility or other network providers in the
TRICARE region where you are enrolled.
UNITED HEALTHCARE
BMI 40 or greater, or BMI 35-39.9 with one or more comorbidities (See UHC specific page)
Dietitian or Nutritionist Consult
Psychology consult
Documentation of Medically Supervised Weight Loss for 6 months
Medical Clearances are discretionary
Covered procedures: Gastric Bypass, Adjustable Gastric Band, Sleeve Gastrectomy
COE not required.