Approval Criteria Checklist for Obesity Surgery*

A reference guide of standard obesity surgery coverage criteria

to assist you in selecting a benefit design plan that will meet your companys needs
DSL# 10-0179 2010 All rights reserved EREM027
*Compiled from multiple sources. See Reference List.
Candidate Qualifications for Surgery
Suggested Additional Candidate Qualifications for Surgery

Documentation that other methods of weight loss have been tried unsuccessfully
(e.g., changes in eating, behavior, increased physical activity and/or drug therapy)

Documentation that performing daily routine activities (e.g., work-related & family
functions) are not possible & quality of life is seriously impaired due to severity of
obesity

Documentation of a formal psychological evaluation demonstrating the patient is a
sound candidate for bariatric surgery & is able to adhere to post surgical behavior
management requirements

Documentation of 3 continuous months of compliance with medically supervised, non-
surgical weight reduction methods by PCP or bariatric surgeon

Documentation of a Pre-Surgery Evaluation: evaluations may vary based on patient
needs & surgeon preference but should at least include the following:
Medical (including clearance from primary care physician)
Surgery (by bariatric surgeon)
Cardiology (in selected patients to uncover potential heart disease & to determine
treatment as necessary)
Pulmonary (including a pulmonary function test & when indicated, a sleep apnea test)
Psychological or psychiatric
Endocrinology
Nutrition

Documentation of participation in a comprehensive Weight Management Program:
Must attend & comply with all outlined activities & visits as established by the bariatric
program. The Weight Management Program should Include, at Pre & Post Surgery,
these components:
____ Nutrition Education ____ Surgeon & RN Visits
____ Personalized Exercise Program ____ Comprehensive Lab Work-ups
____ Psychological Evaluation ____ Bariatric Program Coordinator
____ Support Groups ____ Behavior Management Program
____ Appropriate Diet Supplementation ____ Family & Social Support System
____ Surgery Education

Super Obese BMI 50
Extreme Obesity / Class III Obesity BMI 40
Obese/Class II Obesity BMI 35 39.9 with serious, co-morbid, medical conditions




Hypertension
Type II Diabetes Mellitus
Dyslipidemia
Musculoskeletal, neurological or body size problems precluding or severely impairing qual-
ity of life (employment, family function or ambulation)
Life-threatening Cardiopulmonary Problems (sleep apnea, obesity-hypoventilations syn-
drome or obesity-related cardiomyopathy)
Coronary Artery Disease
Obesity-Related Cardiomyopathy



Provider Qualifications
Approval Criteria Checklist for Obesity Surgery*
A reference guide of standard obesity surgery coverage criteria
to assist you in selecting a benefit design plan that will meet your companys needs
Recognized COE (Center of Excellence/Center of Distinction) facility and/or surgeon
practice by either the Surgical Review Corporation (SRC), the American College of
Surgeons (ACS), Medicare & Medicaid Services (CMS) or a Health Plan, such as
Aetna, BCBS, CIGNA, UnitedHealthcare.

Rural Area Exception See Clarification Points Section



STANDARD
PROCEDURES
Open or Laparoscopic Roux-en-Y (gastric bypass)
LAGB (Laparoscopic Adjustable Gastric Band)
VBG (Vertical Banded Gastroplasty)
BPD (Biliopancreatic Diversion)
LSG (Laparoscopic Sleeve Gastrectomy)

INVESTIGATIONAL
PROCEDURES

Mini Gastric Bypass
Gastric Balloon

Surgical Procedures

Benefit Design Options
Limit coverage to Centers of Excellence facilities & surgeons as defined by CMS
(Medicare & Medicaid Services) the SRC, the ACS or health plan
Provide different patient co-insurance levels based on selecting COE facility or non-
COE facility
Consider employment tenure for bariatric surgery benefit to be accessed
Tie surgical benefit & COE program requirements in with company sponsored wellness
or obesity management programs

Provide a Post-Surgery Incentive Strategy
Some examples include:
Set up criteria for post-surgery maintenance & program adherence. With achievement
of x number of met criteria patient/employee may qualify for paid or partially paid post-
bariatric plastic surgery.
Set up criteria for post surgery maintenance & program adherence. With achievement
of x number of met criteria patient/employee may receive reimbursement dollars back
into their HSA account.
DSL# 10-0179 2010 All rights reserved EREM027
*Compiled from multiple sources. See Reference List.



Clarification Points

Other areas of discussion related to benefits design are listed below.
However, there is not sufficient clinical documentation to make a
recommendation. For each topic, a reference is included to assist with
decision-making.


Repeat Surgery

To include revisions, repeat surgeries and conversion surgeries
https://secure.preferredone.com/Shared/MedicalPolicy/MC_H003.pdf
California Association of Health Plans Consensus Statement; or National Health Plan
Medical Policies (cited below)

A. Conversion to another surgical procedure including all of the following 1-3:
1. Failure to respond to initial gastric bypass
2. Original surgery was at least 2 years prior to repeat procedure
3. Documentation that patient has been enrolled in & compliant with the
previous postoperative program

B. Revision of obesity surgery due to documented surgical complication from the pri-
mary procedure that has not responded to medical treatment including, but not limited
to, one of the following:
1. Obstruction
2. Stricture
3. Dilatation of gastric pouch (only if procedure was successful in inducing
weight loss prior to pouch dilatation)
4. Stoma dilation or stenosis
5. Stoma ulcer
6. Malnutrition

C. Take down (reversal) of obesity surgery (only if documented complication present)

Note: All requests for repeat obesity surgery for staple line breakdown must be
referred for physician review.

Approval Criteria Checklist for Obesity Surgery*
A reference guide of standard obesity surgery coverage criteria
to assist you in selecting a benefit design plan that will meet your companys needs

Rural Area COE Exception

It has been suggested that in rural areas where the volume requirements cannot be
made that the facility must be COE provisional status level with the SRC or Level II
status with the ACS.

http://bbthor.bcbsnd.com/Bulletins/Blue_Cross_Blue_Shield_ND_Medical_Policy/Bariatric_Surgery.htm

DSL# 10-0179 2010 All rights reserved EREM027
*Compiled from multiple sources. See Reference List.




COE REQUIREMENTS

COE standard requirements vary among credentialing bodies but all address:

Surgical Volume & Training:
Usually a minimum of 125 surgeries per year/facility
Surgeon performed at least 125 total bariatric cases lifetime with at least 50 cases
performed in the preceding 12-month period
Processes in place for additional training & training of new surgeons brought into
practice

Medical Director:
Physician Medical Director for bariatric surgery who participates in the relevant deci-
sion-making administrative meetings of the institution

Trained Bariatric Staff & Program Extenders:
Utilization of a designated nurse or physician extender who are dedicated to serving
bariatric surgical patients & who are involved in the continuing education & care
of bariatric patients
Organized & supervised support groups for all patients who have undergone bariat-
ric surgery at the institution
Program dedicated to a long-term patient follow-up goal of at least 75% at five years
for bariatric procedures with a monitoring & tracking system for outcomes

Equipment:
For the care of bariatric surgical patients including furniture, wheel chairs, operating
room tables, beds, radiologic capabilities, surgical instruments & other facilities
suitable for morbidly obese patients

Care Pathways:
Facilitate the standardization of perioperative care for the relevant procedure

Data Collection:
Collect & report outcomes for surgeon & facility



Clarification Points
Approval Criteria Checklist for Obesity Surgery*
A reference guide of standard obesity surgery coverage criteria
to assist you in selecting a benefit design plan that will meet your companys needs
DSL# 10-0179 2010 All rights reserved EREM027
*Compiled from multiple sources. See Reference List.



References
1 Does Preoperative Weight Loss Predict Success with Laparoscopic Roux-en-Y Gastric Bypass.
Bariatric Times, April 2007
2 Oregon Health Resources Commission MedTAP Report June 2007
3 Sjostrom L, et.al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. NEJM 357
(8) August 23, 2007
4 Adams TD, et al. Long Term Mortality after Gastric Bypass Surgery. NEJM 357 (8) August 23,
2007
5 Bray GA. The Missing Link Lose Weight, Live Longer. NEJM 357 (8) August 23, 2007
6 http://www.lapsurgery.com/BARIATRIC%20SURGERY/ASBS.htm
7 CMS National Coverage Decision: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=160
[online]
8 CMS Centers of Excellence List: www.cms.hhs.gov/center/coverage.asp [online]
9 National Institute of Health Consensus Statement on Bariatric Surgery: http://
consensus.nih.gov/1991/1991GISurgeryObesity084PDF.pdf [online]
10 http://www.anthem.com/medicalguidelines/va/f5/s10/t2/pw_037637.pdf [online]
11 https://www.unitedhealthcareonline.com/b2c/cmaIndexResult.do?
channelId=016228193392b010VgnVCM100000c520720a____&htmlFilePath=/ccmcontent/
ProviderII/UHC/enUS/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/MedicalPolicies/
Bariatric_Surgery.htm [online]
12 http://www.humana.com/providers/tools/provider_tools/clinical_healthcare.asp [online]
13 http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/
mm_0051_coveragepositioncriteria_bariatric_surgery.pdf [online]
14 http://www.aetna.com/cpb/medical/data/100_199/0157.html [online]
15 Bradley DW; Sharma C, Bal K. Centers of Excellence in Bariatric Surgery: Design, Implementa-
tion and One-Year Outcomes. Surgery for Obesity and Related Diseases, 2 (2006) 513-517
16 California Association of Health Plans: The Consensus Guidelines on Bariatric Surgery: CAHP
Obesity Initiative Workgroup. June 2006
17 http://bbthor.bcbsnd.com/Bulletins/Blue_Cross_Blue_Shield_ND_Medical_Policy/
Bariatric_Surgery.htm [online]
18 https://secure.preferredone.com/Shared/MedicalPolicy/MC_H003.pdf [online]
19 https://secure.preferredone.com/Shared/MedicalPolicy/MC_H003.pdf [online]
Approval Criteria Checklist for Obesity Surgery*
A reference guide of standard obesity surgery coverage criteria
to assist you in selecting a benefit design plan that will meet your companys needs
DSL# 10-0179 2010 All rights reserved EREM027
*Compiled from multiple sources. See Reference List.