047 Form

Preauthorization Request Form for #379 Surgical Management of Obesity Policy

CLINICAL DOCUMENTATION ▪ Clinical documentation that supports the medical necessity criteria for gastric bypass surgery must be submitted.
▪ If the patient does not meet all the criteria listed below, please submit a letter of medical necessity with a request for Clinical Exception (Individual Consideration) explaining why an exception is justified.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources Refer to our Authorization Manager page for tips, guides, and video demonstrations.

Complete Prior Authorization Request Form for Surgical Management of Obesity (047) using Authorization Manager

For out of network providers: Requests should still be faxed to 888-282-0780. Patient Information Patient Name: ___ Today’s Date: ____ BCBSMA ID#: ___ Date of Surgery: __ Date of Birth: ____ Height/Weight: ___ Blood Pressure: __ Current BMI: _

Physician Information Facility Information Name: ____ Name: _ Address: ___

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Address: ___

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Phone#: ___ Phone#: ____ Fax#: _ Fax#: __ NPI#: _ NPI#: __

Procedure Information Select the appropriate information below: Diagnosis code: E66.01 Morbid (severe) obesity due to excess calories Z68.35 Body mass index (BMI) 35.0-35.9, adult Z68.36 Body mass index (BMI) 36.0-36.9, adult Z68.37 Body mass index (BMI) 37.0-37.9, adult

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  Z68.38 Body mass index (BMI) 38.0-38.9, adult Z68.39 Body mass index (BMI) 39.0-39.9, adult Z68.41 Body mass index (BMI) 40.0-44.9, adult Z68.42 Body mass index (BMI) 45.0-49.9, adult Z68.43 Body mass index (BMI) 50-59.9 , adult  Z68.44 Body mass index (BMI) 60.0-69.9, adult Z68.45 Body mass index (BMI) 70 or greater, adult Other diagnoses or co-morbid conditions:___

  Procedure codes for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
   43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric by-pass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)  43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components)  43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)  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 surgery, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy  43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)

  Procedure codes for Medicare Advantage Plans only:  43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric by-pass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)  43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components)  43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)  43845 Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50-100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)  43846 Gastric restrictive surgery, 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

  The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: Procedure codes:  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 The following CPT code is considered investigational for Commercial Members: Managed Care (HMO and POS), PPO and Indemnity: Procedure codes:  43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption  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  43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption

  Patient Selection Criteria

  Patient is morbidly obese with a BMI >40kg/m2 or the patient has a BMI >35kg/m2 with one or more severe co-morbidities that are likely to reduce quality of life and/or life expectancy. Please check to indicate individual’s co-morbidities:

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   Coronary Artery Disease  Pickwickian syndrome  Pseudo-tumor Cerebri  Obesity-related cardiomyopathy  Obesity related pulmonary hypertension  At least stage 1 hypertension based on JNC-VII (SBP>140 and/or DBP>90) after combination pharmacotherapy  Sleep Apnea/Obstructive Sleep Apnea  Individual has a BMI >30kg/m2 and has type 2 diabetes.  Other co-morbidity: ___

  The physician has indicated that the patient:  Is well-informed and well-motivated with acceptable operative risks  Has had a failure of other non-surgical approaches to long-term weight loss  Has a strong desire for substantial weight loss  Is enrolled in a pre-operative multidisciplinary evaluation and care program that includes behavioral health, nutrition, and medical management

  *BCBSMA comprises Blue Cross Blue Shield of Massachusetts, Inc. and Blue Cross and Blue Shield of Massachusetts HMO Blue ®, Inc. ®Registered Mark of the Blue Cross Blue Shield Association. PEP-2658 (rev 5/24)