Currentblue cross blue shield - tennesseePolicy N/A

Bariatric Surgery Authorization Request Form

Administrative authorization request form for bariatric surgery for BlueCross BlueShield of Tennessee commercial plans. Collects member, provider, surgical, clinical eligibility and documentation details to support prior authorization for initial or subsequent bariatric procedures; not a coverage policy itself.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyBariatric Surgery Authorization Request Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionFax the completed form with clinical documentation to 1-866-558-0789 or submit online via Availity; include CPT and ICD-10 codes, operative history, and supporting tests/notes.

POLICY UPDATE CHANGES

No material changes — administrative authorization form; not a coverage policy.

FormDocument Type

CommercialIntended Payer Population

Initial+SubsequentSupported Request Types

Bariatric Surgery Authorization Request Form — BlueCross BlueShield of Tennessee

This is an administrative prior-authorization request form used by BlueCross BlueShield of Tennessee to collect member demographics, provider/facility information, surgical details, and clinical eligibility checklists for initial or subsequent bariatric procedures (including conversion, correction/revision, or reversal). The form includes placeholders for procedure and diagnosis coding and collects supporting documentation such as operative history, preoperative and nadir weights/dates, and relevant tests.

Form clinical eligibility checklists

Candidate for bariatric surgery (form checklist)

Select all that apply; intended to document that the patient meets program and clinical prerequisites:

Age: Individual is 13 years of age or older>= 13 years
Correctable causes for obesity are not identified (e.g., endocrine disorder)
Substance abuse: No current substance abuse
Prior nonsurgical treatment: Patient has failed to achieve and maintain significant weight loss with nonsurgical treatment
Postoperative adherence: Patient will be able to adhere to postoperative care (judged to be committed and able to participate in postoperative requirements)
Multidisciplinary program: Patient is receiving treatment in a multidisciplinary program experienced in obesity surgery that can provide ALL of: preoperative medical consultation, preoperative mental health consultation with conclusion of no current untreated eating disorders or psychiatric conditions and ability/willingness to adhere to post-op care requirements, nutritional counseling, and patient support programs

Subsequent surgery - Option 1 (conversion to different gastric restrictive procedure)

All of the following must be met for conversion requests:

Conversion request: Patient is requesting conversion from the initial surgical procedure to a different type of gastric restrictive procedure
Non-investigational: Requested procedure is not an investigational procedure
Time since initial surgery: Request is one year or more since the initial surgery>= 1 year
Attach pertinent records to document details of the initial surgery (initial surgery date, preoperative weight/date, nadir weight/date).
Weight loss threshold:

Subsequent surgery - Option 2 (correction/reversal of prior surgery)

Requirements for correction/reversal requests:

Physician-documented complication: There must be a physician-documented complication related to the original surgery
Attach objective imaging/records: Pertinent objective imaging reports and records must be attached to document the complication

BMI 30.0-34.9 documentation requirement

When BMI is 30.0 to 34.9 additional documentation is required:

Pertinent labs: List or attach pertinent labs
DME or tests: List or attach DME (e.g., CPAP) or tests
Supporting diagnoses: List or attach diagnoses required to support the request per policy definitions for obesity severity

Thresholds

Age>= 13 years

Time since initial surgery for conversion>= 1 year

Weight loss threshold after initial procedure< 50% of pre-operative excess body weight

BMI band requiring extra documentation30.0 - 34.9

What providers must submit and document

Prior Authorization

Submit completed authorization form with clinical records

Fax the completed authorization form and clinical documentation to 1-866-558-0789 or submit online via Availity. Include the requested procedure CPT code(s) and ICD-10 diagnosis code(s), a complete operative history, and supporting tests/notes with the submission.

Documentation Required

Multidisciplinary program documentation

Document that the patient is being treated in a multidisciplinary bariatric program and attach evidence of: preoperative medical consultation; preoperative mental health consultation with conclusion of no current untreated eating disorders or psychiatric conditions and ability/willingness to adhere to postoperative care requirements; nutritional counseling; and participation in patient support programs.

Preoperative medical consultation
Preoperative mental health consultation with conclusion of no untreated eating disorders or unmanaged psychiatric conditions
Nutritional counseling
Patient support program participation

Documentation Required

For conversion requests attach prior surgery records

For conversion requests attach pertinent records documenting the initial surgery, including the type of initial procedure and date, the preoperative weight and date, the lowest (nadir) weight achieved and date, and weight trajectory. Ensure documentation shows the request is one year or more since the initial surgery as required for conversion criteria.

Initial surgery type and completion date
Preoperative weight and date
Nadir (lowest) postoperative weight and date
Weight trajectory since initial surgery
Evidence that ≥ 1 year has passed since initial surgery

Documentation Required

For correction/reversal attach objective evidence of complication

For correction or reversal requests attach objective evidence of the complication: include a physician-documented complication related to the original surgery and pertinent objective imaging reports and related records to support the revision/reversal request.

Physician-documented complication related to the original surgery
Pertinent objective imaging reports and related records

Documentation Required

BMI 30.0-34.9 supplemental documentation

When the member's BMI is 30.0 to 34.9, attach supplemental documentation such as pertinent laboratory results, information about related durable medical equipment (for example CPAP), other relevant tests, or diagnoses required by the policy definitions for obesity severity to support the surgical indication.

Pertinent labs
Durable medical equipment documentation (e.g., CPAP)
Relevant tests or diagnostic documentation per policy definitions

Documentation Required

Attesting surgeon signature

The attending/operating surgeon must sign and date the form attesting they have reviewed the patient's clinical information and recommend the requested bariatric surgery.

Operating/attending surgeon signature
Date of signature attesting review and recommendation

Definitions referenced on form

Definitions

Multidisciplinary programProgram experienced in obesity surgery that provides preoperative medical consultation; preoperative mental health consultation concluding no current untreated eating disorders or psychiatric conditions and patient able/willing to adhere to post-op care; nutritional counseling; and patient support programs.

This document functions as an administrative authorization form to be faxed or submitted online with clinical documentation to support the prior-authorization decision for bariatric surgery. It captures required provider attestations and signature, facility/provider identifiers, and prompts for the clinical information and attachments needed for review.

Not all contracts include obesity surgery benefits; the form instructs submitters to verify member benefits prior to submission.

CPT (placeholder)	Procedure(s) requested - provider to enter relevant CPT code(s)
ICD-10 (placeholder)	Diagnosis code(s) - provider to enter relevant ICD-10 code(s)

OpenPayer

Bariatric Surgery Authorization Request Form

Bariatric Surgery Authorization Request Form — BlueCross BlueShield of Tennessee

Form clinical eligibility checklists

What providers must submit and document

Form coding fields and placeholders

Definitions referenced on form

Revision history and document changes