INSURANCE AUTHORIZATION REQUIREMENTS

PHOENIX BARIATRIC CENTER, PLC

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 Multi-disciplinary 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/ anti-depressant 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

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

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

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.