Bariatric Surgery Benefit (Health Plan for State of Louisiana Employees and Retirees)
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Defines eligibility, required preoperative steps, prior authorization, coverage limits, facility accreditation, cost-sharing, and exclusions for bariatric surgery benefits for Plan Participants in the Health Plan for State of Louisiana Employees and Retirees.
No material clinical or coverage changes in this revision.
Coverage Criteria
Bariatric Surgery Benefit - Enrollment and Coverage Criteria
Covered when ALL of the following are met:
Item 1
Item 2
Item 3a
Item 3b
Item 3c i-iv
Items 4 and 5
Item 4a-e
Item 9
Item 11
Benefits for prescriptions or supplements intended for weight management or nutrition after the Bariatric Surgery are excluded, regardless of claim of medical necessity.
Benefits for fat or skin removal surgery, or similar services, are excluded, regardless of claim of medical necessity.
For members who have NOT been approved for the Bariatric Surgery Benefit program, benefits are excluded, regardless of claim of medical necessity, for services, surgery, supplies, treatment or expenses related to: (a) weight loss programs (whether for medical reasons or under medical supervision) other than for Plan Participants in the Plan's Bariatric Surgery Benefit program or another program approved by the Plan Administrator; (b) any Bariatric Surgery; and (c) obesity or morbid obesity, except as required by law.
Services related to weight loss programs, bariatric surgery, or treatment of obesity are excluded for members not approved for the Bariatric Surgery Benefit program, irrespective of medical necessity, except where coverage is required by law.
Clinical Thresholds & Coding Summary
Provider Requirements, Prior Authorization & Denial Risks
Obtain prior authorization before pre-op services and surgery
Prior authorization must be obtained for preoperative services and for the bariatric surgical procedure; no benefits will be payable without prior authorization.
Complete and document ≥5 months medically supervised weight-loss program
Complete at least five (5) months of a medically supervised weight loss program prior to authorization, and document nutritional counseling, pre-operative nutritional assessment, and psychological assessment with clearance.
- Five (5) or more months of a medically supervised weight loss program must be completed.
- Document nutritional counseling and pre-operative nutritional assessment.
- Document a psychological assessment performed by a licensed mental health practitioner with clearance to proceed.
Document program completion, counseling, psychological clearance, and testing
Maintain documentation showing completion of the medically supervised weight loss program (≥5 months), nutritional counseling and assessment, psychological assessment and clearance, and any routine preoperative testing directed by the treating provider.
- Records of the ≥5 month medically supervised weight loss program.
- Pre-operative nutritional assessment and counseling notes.
- Psychological assessment report and clearance.
- Routine testing results (labs, radiology, respiratory, nutritional and psychological consults) as directed.
Record BMI and compliance with medical/dietary management
Document the member's BMI to show eligibility: BMI ≥40, or BMI ≥35 with at least two comorbidities associated with severe obesity, and evidence of compliance with medical and dietary management activities.
- BMI documentation meeting: ≥40 OR ≥35 plus ≥2 comorbidities (e.g., hypertension, sleep apnea, diabetes, severe osteoarthritis, cardiopulmonary conditions).
- Evidence of compliance with diet, exercise, and other medical/dietary management activities.
Use MBSAQIP‑accredited Network facility and document accreditation
Ensure all bariatric surgery services are performed in a Network Provider facility that holds MBSAQIP accreditation; include documentation of facility MBSAQIP accreditation with the request for services.
- Services must be rendered in a Network Provider facility holding Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®) accreditation.
- Facility accreditation documentation should be available for verification.
Services require Plan Administrator authorization for payment
No payment will be made unless the Plan Administrator authorizes the services; obtain authorization before delivering covered bariatric procedures.
Failure to obtain prior authorization will result in no benefits payable
No benefits are payable unless prior authorization is obtained; providers must secure prior authorization for preoperative services and the bariatric surgery itself.
Denial risk when annual program limit of 300 surgeries is reached
Authorizations for pre-operative services will not be approved once the program reaches its annual limit of 300 participating Plan Participants; a waiting list will be established when 300 participants qualify.
- Program limited to 300 surgeries per calendar year; participation is first come, first serve.
- No additional pre-op authorizations after 300 participants until a participant exits or a new calendar year begins.
- A waiting list is maintained on a first come, first serve basis.
Background
Bariatric surgery is intended to treat severe obesity using surgical methods recognized for long-term reversal of severe obesity. The Plan restricts covered procedures to specified operations and requires preoperative medical, nutritional, and psychological optimization before surgery. Coverage is limited to eligible Plan Participants who meet enrollment, BMI, preoperative program, and authorization requirements, and procedures must be performed at an MBSAQIP-accredited Network Provider facility.
Definitions
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