Prior Approval for Obesity Surgery for (FEP UM only)
Provider Tool Effective Date: 01/01/2012
Complete and fax to:
(800) 732-8318 (for CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, VA, WI only)
Patient Name ID ______
Patient Date of Birth: Proposed Date of Service:
Provider name or ID
Facility name or ID #:
Submitted by: Date:
Phone: Fax:
Request is for: Initial Gastric Restrictive Surgery Repeat Gastric Surgery Gastric Surgery Revision
Setting: Outpatient Inpatient - If inpatient, number of days requested: ______
Primary Diagnosis Code(s)______
Procedure Code:
43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption,
43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components)
43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only
43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only
43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only
43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components
43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy)
43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
43845 Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common
channel) to limit absorption (biliopancreatic diversion with duodenal switch)
43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy
43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption
43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)
43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only
**Note- For a Gastric Restrictive Surgery Revision due to complications- Please submit medical documentation supporting medical necessity.**
Is the patient at least 18 years of age? Yes No
Has the patient been morbidly obese for at least 2 yrs? Yes No
Definition of Morbid Obesity:
A condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a
BMI of 35 or more with co-morbidities who has failed conservative treatment. The criterion to “fail
conservative treatment” applies to both individuals with a BMI of 40 or more and individuals with a BMI of 35 or more who have co-morbid conditions.
Weight______(in lbs)Height______(in inches)BMI______
Does the patient have a history of significant co-morbid conditions (Check all that apply):
Diabetes (Type 1 or 2) Cardiovascular Disease Hypertension Severe Sleep Apnea
Chronic Obstructive Pulmonary Disease (COPD) Cardiomyopathy Asthma
Other (Please List) ______
Within the last 18 months, has the member participated in at least 3 months of a medically supervised
weight loss program, including nutritional counseling without success? Yes No
Date Range of medically supervised program participation: Begin Date______End Date______
Name of MD or Nutritionist Supervising______Phone Number______
Has the patient had a pre-operative nutrition assessment & nutritional counseling about
pre- and post-operative nutrition, eating, and exercise? Yes No
Does the patient have a history of smoking? Yes No
Does the member currently smoke? Yes No
Date member quit smoking______
Does the patient have a history of substance abuse? Yes No
If Yes, has the patient been treated for substance abuse within the last year? Yes No
Has the patient had a pre-op mental health evaluation by a licensed mental health
professional that states patient is able to understand and adhere to pre- & post-operative program ? Yes No
GASTRIC SURGERY --REPEAT GASTRIC SURGERIES ONLY
**Note- Repeat Gastric Revision Surgeries must meet all of the criteria for Initial Gastric Surgeries***
Previous Gastric Restrictive Surgery has been greater than 24 months Yes No
Date of Gastric Restrictive Surgery______
Was the weight loss from the initial procedure was less than 50% of the
member’s excess body weight at the time of the initial procedure? Yes No
Did the patient comply with previously prescribed postoperative
nutrition and exercise program? Yes No
I attest the information provided is true and accurate to the best of my knowledge. I understand that Anthem may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.
______
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)* Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
CHECKLIST OF DOCUMENTS TO SUBMIT WITH SIGNED FORM:
Mental Health Evaluation Nutrition Evaluation Notes
SURGEON SIGNATURE______