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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.