Know when CareSource releases new policies or updates existing guidance.
Monitor payer policy activity
Receive email alerts as soon as relevant payer policies are published or updated.
Defines coverage criteria, documentation requirements, contraindications, and referral guidance for metabolic and bariatric surgery for CareSource members under the Arkansas PASSE policy.
Policy Summary
PayerCareSource
PolicyMetabolic and Bariatric Surgery
Policy CodePolicy N/A
Change TypeEligibility, documentation, and preop requirement updates
Effective DateJun 1, 2026
Last ReviewJun 19, 2024
Next Review DateN/A
Key ActionSubmit prior authorization with multidisciplinary documentation and a psychological evaluation completed within the past 6 months.
Added Asian BMI criteria to surgical eligibility in Sec. D.I.C.1 and 2.
Removed mandatory preoperative weight loss program participation requirement.
Updated multidisciplinary documentation and mental health evaluation timing and content requirements.
13+minimum member age allowed for coverage (years)
≥35primary BMI threshold for coverage
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.
30–34.9lower BMI pathway + comorbidity
≥30BMI pathway with uncontrolled T2DM
>55refer to accredited center when
Coverage Criteria for Metabolic & Bariatric Surgery
Initial Eligibility
Covered when ALL of the following are met:
Primary criteria: Member has a primary diagnosis of obesity; member is 13 years of age or older; one of the BMI pathways is met (see nested).
BMI pathways: Satisfy any ONE of the three BMI-based pathways below.
Pathway 1: BMI ≥35 kg/m2 (≥32.5 kg/m2 in Asian patients).BMI ≥35 (≥32.5 Asian)
Pathway 2: BMI 30–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian patients) AND at least one serious obesity-related condition.BMI 30–34.9 (27.5–32.4 Asian) + comorbidity
Comorbidities include high risk for Type II diabetes (insulin resistance, prediabetes, metabolic syndrome), osteoarthritis of knee or hip (including to improve joint replacement outcomes), obstructive sleep apnea, non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, pseudotumor cerebri, gastroesophageal reflux disease, severe urinary stress incontinence, poorly controlled hypertension on multiple drug therapy, and other serious obesity-related conditions listed in policy.
Pathway 3: BMI >30 kg/m2 with Type II diabetes mellitus if documentation shows Type II DM is inadequately controlled despite optimal medical treatment with oral or injectable medications, including insulin.BMI >30 + inadequately controlled T2DM
Requires documentation that Type II diabetes remains inadequately controlled despite optimal medical therapy.
Required Documentation
Coverage requires submission of ALL of the following documentation:
Documentation list: Evidence of informed consent; letter from the primary care physician or appropriate specialist documenting medical necessity and that health-related behaviors (e.g., smoking) have been addressed; evidence member is receiving care in a multidisciplinary program providing preoperative medical and mental health consultation, nutritional counseling, exercise counseling, and patient support programs; substance use screening results and documentation that harm-reduction was discussed; documentation that nicotine risks were discussed; evidence that vitamin B deficiencies were monitored and treated as needed prior to surgery; endocrine study results (T3, T4, blood sugar, and 17‑Keto Steroid or plasma cortisol) demonstrating absence of endocrine disease; psychological evaluation performed within the past 6 months by a treating behavioral health provider documenting co-existing psychiatric conditions, family and social support, understanding of the procedure, and stability to proceed (including ability to understand risks/benefits, change lifestyle, follow postoperative care, withstand surgery, and low risk of suicidality); complete history and physical including assessment, diagnoses, height, weight, BMI, and treatment plan (including exclusion/diagnosis of genetic or syndromic obesity when applicable); and for women of reproductive potential, documented conception counseling with agreement to avoid pregnancy for at least one year postoperatively and discussion of pregnancy-related nutritional risk.
Procedures that are experimental or investigational are not covered. Examples specifically listed in the policy include endoscopic bariatric and metabolic therapies such as intragastric balloon (IGB), endoscopic sleeve gastroplasty (ESG), and aspiration therapy (AT).
Surgery is considered contraindicated and therefore not medically necessary for members with any of the following conditions: a medically correctable cause of obesity; current or planned pregnancy within one year of the procedure; active suicidality or self-harm; active psychosis; active substance use disorder or ongoing substance abuse within the previous year; severe coagulopathy; uncontrolled or untreated eating disorders; or inability to comply with long-term postoperative follow-up care.
Coding and BMI Thresholds
Experimental / Not Covered ProceduresCPTExperimental
Endoscopic bariatric and metabolic therapies
Includes Intragastric balloon (IGB)
Endoscopic sleeve gastroplasty (ESG)
Aspiration therapy (AT)
inv-06: BMI thresholds and diabetes control — primary BMI thresholds, lower Asian BMI cutpoints, and diabetes-related pathway
Primary adult BMI thresholdsBMI ≥35 kg/m2 (≥32.5 kg/m2 in Asian patients); or BMI 30–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian patients) with at least one serious obesity‑related condition
Diabetes-specific pathwayBMI >30 kg/m2 with Type II diabetes mellitus that is inadequately controlled despite optimal medical therapy (oral or injectable, including insulin) — documentation of inadequate control required
Age requirementMember is 13 years of age or older
Additional documentationComplete history and physical with height, weight, BMI; evidence of multidisciplinary care (preop medical, mental health, nutrition, exercise counseling, and patient support); psychological evaluation within 6 months; PCP/specialist letter supporting medical necessity
Provider Actions, Authorization & Denial Risks
Prior Authorization
Prior Authorization Required
Prior authorization from CareSource is required before scheduling metabolic and bariatric surgery. Submit requests to the prior authorization unit and obtain approval to avoid claim denials or retrospective review.
Prior authorization required for all bariatric/metabolic surgical procedures
Obtain approval prior to surgery scheduling
Documentation Required
Required Documentation for Authorization
The attending surgeon (and/or PCP) must submit complete clinical documentation to support the authorization request. Incomplete documentation may delay review or result in denial.
Evidence of informed consent
PCP/specialist letter documenting medical necessity and addressed health behaviors (e.g., smoking, adherence)
Background and Rationale
Obesity is common and associated with multiple serious comorbidities; for members who cannot achieve adequate weight control with noninvasive measures, metabolic and bariatric surgery can provide substantial weight reduction and improvement in associated conditions. The policy therefore defines clinical eligibility and safety criteria, requires comprehensive preoperative assessment (including history and physical, BMI, and multidisciplinary evaluations), and identifies members who should be referred to an accredited comprehensive center (for example, those with BMI >55 kg/m2).
Definitions
BMI — definition
DefinitionBody Mass Index (BMI) for Adults is a person's weight in kilograms divided by the square of height in meters.
UseBMI is used in this policy to determine eligibility pathways for metabolic and bariatric surgery based on absolute and ethnicity‑adjusted cutpoints.
Calculation noteExpressed as kg/m2; policy specifies adjusted lower cutpoints for Asian patients where applicable.
Weight Loss Surgery — definition
Weight Loss Surgery (term)Also referred to as bariatric and metabolic surgery — operations that affect weight and metabolic health and can treat obesity and related conditions such as diabetes, high blood pressure, sleep apnea, and high cholesterol.
ScopeIncludes procedures intended to produce durable weight reduction and metabolic improvement; policy uses these terms interchangeably.
Policy Summary
PayerCareSource
PolicyMetabolic and Bariatric Surgery
Policy CodePolicy N/A
Change TypeEligibility, documentation, and preop requirement updates
Effective DateJun 1, 2026
Last ReviewJun 19, 2024
Next Review DateN/A
Key ActionSubmit prior authorization with multidisciplinary documentation and a psychological evaluation completed within the past 6 months.
Documentation of multidisciplinary treatment participation: preoperative medical consultation, preoperative mental health consultation, nutritional counseling, exercise counseling, and patient support programs
Substance use screening results and evidence that harm reduction was discussed
Evidence nicotine-risk counseling and treatment of vitamin B deficiencies prior to surgery
Endocrine study results (T3, T4, blood sugar, 17-Keto Steroid or Plasma Cortisol) showing no untreated endocrine disease
Psychological evaluation within the past 6 months documenting psychiatric conditions, family/social support, understanding of procedure, decisional capacity, and stability (including absence of suicidality or significant risk of decompensation)
Complete history and physical with assessment, listing of diagnoses, height, weight, BMI, treatment plan, and any genetic/syndromic obesity exclusion
For women of reproductive capacity: documentation of conception counseling and agreement to avoid pregnancy for at least one year post-op
Denial Risk
Contraindications That Trigger Denial
The following contraindications are review triggers and, when present as active conditions, will result in denial of authorization for bariatric surgery.
Active suicidality or self-harm
Active psychosis
Active substance use disorder or ongoing substance abuse within the previous year
Uncontrolled and untreated eating disorders
Inability to comply with postoperative long-term follow-up care
Current or planned pregnancy within one year of the procedure
A medically correctable cause of obesity
Severe coagulopathy
Step Therapy
Step Therapy / Preoperative Program Not Applicable
There is no step therapy sequence or mandatory preoperative weight-loss program required for authorization. Providers should still document conservative management efforts where applicable, but lack of a preoperative weight-loss program is not a basis for denial.
No step therapy sequencing is applicable
Mandatory preoperative weight-loss requirement has been removed — conservative measures may be documented but are not required for coverage
Clinical impactRecognized for effectiveness in treating obesity and metabolic diseases beyond weight loss alone.
Behavioral Health Provider — definition and examples
DefinitionBehavioral Health Provider: a provider of behavioral health services, including a psychologist, psychiatrist, or psychiatric nurse practitioner.
Role in authorizationPer policy, a behavioral health provider must perform a psychological evaluation within the past 6 months documenting psychiatric conditions, family/social support, understanding of the procedure, and stability to proceed.
ExamplesExamples explicitly listed in policy: psychologist, psychiatrist, psychiatric nurse practitioner.