State Sponsored Business, Anthem Blue Cross and Blue Shield

State Sponsored Business, Anthem Blue Cross and Blue Shield

Bariatric Surgery Physician Verification Form

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In order to assist you in obtaining authorization for bariatric surgery we need clinical information to support the medical necessity for this procedure. It is recommended you review the Anthem guidelines on Please complete this form and attach the appropriate supporting documentation. Once this form is completed and signed, please fax to 18664062803.

Member Information

Last Name:First Name:

Anthem ID Number: Date of Birth:

Date of Most Recent Medical Examination:

Height: Weight:

BMI: Date of BMI:

Co-Morbid Conditions: Yes (if Yes, list below.) No

1. 2.

3. 4.

Conservative Therapy

Date Started: Date Ended:

Describe (attach additional pages if necessary):

Outcome:Weight loss of lbs. over months

Explanation of member’s success or failure of conservative treatment:

Pre-Operative Medical Consultation

Performed on Date:

Result: Acceptable for Bariatric Surgery Not acceptable for Bariatric Surgery

Psychiatric Conditions

List those that would make it difficult for the member to understand, tolerate, and comply with all phases of care and attach notes. If none identified, state “none”.

MemberLast Name: Member First Name:

Pre-Operative Mental Health Assessment

Performed on Date:

Name of Mental Health Professional Performing Assessment:

Title of Mental Health Professional Performing Assessment:

Result: Acceptable for Bariatric Surgery Not acceptable for Bariatric Surgery

Date member received information about the reasonable outcomes of bariatric surgery /
Date member received a thorough explanation of the risks, benefits, and uncertainties of the procedure

Dietician/Nutritionist Evaluation

Please remember to attach evaluation.

Performed on Date:

Determination: Acceptable for Bariatric Surgery Not acceptable for Bariatric Surgery

Pre-operative dietary evaluations and nutritional counseling were performed on:

Date: / Date: / Date: / Date:
Date: / Date: / Date: / Date:

Post-operative dietary evaluations and nutritional counseling
are included in the treatment plan: Yes No

The current treatment plan includes counseling regarding exercise, psychological issues, and the availability of supportive resources when needed: Yes No

Proposed surgery with codes:

Gastric bypass length cmCodes:

GastroplastyCodes:

Biliopancreatic bypass with dudodenal switchCodes:

Laparoscopic adjustable gastric bandingCodes:

I do attest that the above is true and accurate to the best of my knowledge.

Print Physician Name:

Physician Signature*:

Date:

* The physician performing the surgery must sign this form. Stamped signatures will not be accepted.