CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Commercial Utilization Management Bariatric Surgery Authorization Request Form (prior authorization)

This document is the BlueCross BlueShield of Tennessee Commercial Utilization Management authorization request form used to request prior authorization for bariatric surgery (initial, revision, conversion, or reversal) for commercial members. It governs submission requirements and attestation statements for providers and multidisciplinary programs.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyCommercial Utilization Management Bariatric Surgery Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization using the Commercial Utilization Management Bariatric Surgery Authorization Request Form via Availity or the provider portal and include required documentation and attestations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Age ≥13minimum patient age listed as eligible

BMI rangesBMI capture and special instructions

1 yearinterval for conversion

50%insufficient weight-loss threshold

Coverage Criteria for Bariatric Surgery

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Initial bariatric surgery criteria

Covered when ALL of the following are met

Primary eligibility: Individual is 13 years of age or older; correctable causes for obesity are not identified (e.g., endocrine disorder); no current substance abuse; patient has failed to achieve and maintain significant weight loss with non-surgical treatment; patient will be able to adhere to postoperative care (e.g., judged to be committed and able to participate in postoperative requirements); patient is receiving treatment in a multidisciplinary bariatric program that provides preoperative medical consultation, preoperative mental health consultation (conclusion that there are no current untreated eating disorders or psychiatric conditions and patient is able and willing to adhere to post-op care requirements), nutritional counseling, and patient support programs.

Form requires checking each applicable box and attesting physician signature.

Conversion criteria

Subsequent surgery (conversion) covered when ALL of the following are met

Conversion requirements: Patient is requesting conversion from the initial surgical procedure to a different type of gastric restrictive procedure; the requested procedure is not an investigational procedure; the request is one year or more since the initial surgery; weight loss is less than 50% of initial procedure pre-operative excess body weight or there is excessive weight regain one year or longer after prior bariatric surgery; current substance abuse is not identified.>= 1 year; <50% excess weight loss

Documentation of initial surgery details, preoperative and nadir weights and dates required (attach pertinent records).

Revision or reversal criteria

Subsequent surgery (revision or reversal) covered when ONE of the following applies

Revision/Reversal requirements: Member requires correction (revision) or reversal of the initial surgery due to a physician-documented complication related to the original surgery; the requested procedure is not an investigational procedure.

Attach description of the complication and pertinent imaging reports documenting the complication; attestation by physician required.

The form specifies that a requested bariatric procedure is not covered if it is an investigational procedure. Providers must confirm the planned procedure is an established, non‑investigational bariatric surgery before submitting an authorization request.

Not all member contracts include coverage for obesity surgery. The form instructs providers to verify benefits prior to submitting; if the member's contract does not include obesity surgery benefits, the submission may be denied as the service is not covered under the contract.

Coding, Age, and Clinical Thresholds

Requested procedure and diagnosis codesmixed

CPT code	Requested procedure CPT code to be entered on form
ICD-10 diagnosis code(s)	Diagnosis code(s) to be entered on form

inv-07: Age — >= 13 years

Minimum eligible ageIndividual is 13 years of age or older

Form fieldPart II page includes checkbox to confirm age eligibility (13 years or older)

AttestationAttesting physician must sign confirming eligibility criteria including age

inv-08: BMI — Form collects BMI; special documentation required for BMI 30.0–34.9

BMI captured on formCurrent weight, height and BMI fields are collected on Part II of the form

Special documentation for BMI 30.0–34.9If the member's BMI is 30.0 to 34.9, list or attach pertinent labs, DME (e.g., CPAP), tests or diagnoses required to support the request

Use in eligibility checkboxesForm includes checkboxes to document that patient meets clinical guidelines including BMI-related items

inv-09: Interval since initial surgery for conversion — >= 1 year

Minimum interval for conversionThe request is one year or more since the initial surgery (>= 1 year)

Documentation requirementPart III requests details of initial surgery and dates to confirm timing

Applies to conversion optionRequirement listed under Option 1 (conversion) on the form

inv-10: Insufficient weight loss threshold after prior surgery — < 50% of initial procedure pre-operative excess body weight

Insufficient weight loss thresholdWeight loss is less than 50% of initial procedure pre-operative excess body weight

Alternate triggerExcessive weight regain one year or longer after prior bariatric surgery also qualifies

ContextListed as a requirement for conversion (Option 1) and requires documentation of preoperative and nadir weights/dates

Submission Requirements and Provider Responsibilities

Denial Risk

Benefit Verification Required

Please complete benefit verification before submitting a prior authorization request. Not all contracts include obesity surgery benefits; requests may be denied if the member's contract does not include obesity surgery benefits.

Verify member benefits and eligibility for obesity surgery under the member's contract prior to submitting the authorization request.

Prior Authorization

Submission Channel and Form

Prior authorization must be submitted using the Commercial Utilization Management Bariatric Surgery Authorization Request Form. Tennessee providers may submit authorization requests at any time in Availity®. Out-of-state providers may submit authorization requests through their provider portal or Cohere®. If you have questions about submitting a prior authorization request, call (423) 535-5717, option 2, or contact your eBusiness Network Manager.

Submit the completed form as an attachment through Availity (TN) or the provider portal / Cohere (out-of-state).
Contact for submission questions: (423) 535-5717, option 2.

Documentation Required

Required Documentation

Submit a completed authorization form that includes member demographics, requested procedure CPT code(s) and ICD-10 diagnosis code(s), provider and facility information, tentative surgery date, and the bariatric surgeon's attestation and signature. Attach supporting clinical documentation as described below.

Completed Commercial Utilization Management Bariatric Surgery Authorization Request Form (Parts I–III as applicable).
Member demographics: name, DOB, member ID, contact information.
Procedure(s) requested with CPT and ICD-10 codes.
Provider and facility details: names, NPIs or provider IDs, addresses, phone/fax, type of admission, tentative surgery date.
Surgeon attestation/signature and date.
Pertinent clinical documentation: prior operative records (if revision), imaging, lab results, sleep study/DME for BMI 30.0–34.9 when applicable, mental health and nutritional evaluations, and multidisciplinary program documentation.
For revisions/reversals: documentation of initial surgery details and physician-documented complication related to the original surgery (if applicable).

Documentation Required

Conservative Therapy and Program Participation

Document failure of conservative (non-surgical) weight-loss efforts and enrollment/participation in a multidisciplinary bariatric program. The attending/attesting physician or multidisciplinary program should confirm that the patient has failed to achieve and maintain significant weight loss with non-surgical treatment and is receiving or has access to preoperative medical consultation, preoperative mental health consultation, nutritional counseling, and patient support programs.

Evidence of failed non-surgical treatment and weight-loss attempts.
Multidisciplinary program participation documentation including preoperative medical and mental health consultations (mental health evaluation must conclude no untreated eating disorders or psychiatric conditions that would preclude surgery), nutritional counseling, and patient support program involvement.
For revisions: documentation that the patient is receiving treatment in an appropriate multidisciplinary program and, if applicable, details of the complication necessitating correction.

Background

This authorization form documents clinical eligibility and program requirements for bariatric surgery. It collects patient demographics and clinical details including age, BMI and weight data, absence of correctable endocrine causes or current substance abuse, and documentation of prior non‑surgical treatment failure. The form also requires attestation that the patient is participating in a multidisciplinary bariatric program offering preoperative medical, mental health, nutritional counseling and support, and that the patient can adhere to postoperative care. For subsequent procedures (conversion, revision, reversal) the form captures timing, prior surgery details, and supporting imaging or records as applicable.

OpenPayer

Commercial Utilization Management Bariatric Surgery Authorization Request Form (prior authorization)

Coverage Criteria for Bariatric Surgery

Coding, Age, and Clinical Thresholds

Submission Requirements and Provider Responsibilities

Background

Definitions