CurrentCareSourcePolicy N/A

Metabolic and Bariatric Surgery coverage

Defines medical necessity, documentation, contraindications, and referral guidance for metabolic and bariatric surgery for CareSource Arkansas PASSE members aged 13 and older.

Policy Summary

PayerCareSource

PolicyMetabolic and Bariatric Surgery coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2022

Next Review DateN/A

Key ActionObtain prior authorization with documentation showing member is ≥13, has failed a ≥6-month supervised weight-loss program within the past 2 years, and meets BMI criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13+minimum member age eligible

BMI ≥40criterion for surgery without comorbidity

BMI ≥35criterion with ≥1 serious obesity-related condition

BMI >30criterion if Type II diabetes inadequately controlled

6 mominimum supervised weight-loss attempt duration

Coverage Criteria for Metabolic & Bariatric Surgery

Policy Summary

PayerCareSource

PolicyMetabolic and Bariatric Surgery coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2022

Next Review DateN/A

Key ActionObtain prior authorization with documentation showing member is ≥13, has failed a ≥6-month supervised weight-loss program within the past 2 years, and meets BMI criteria.

SourceLink

On This Page

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Initial surgery medical necessity

Covered when ALL of the following are met:

Core eligibility: Member has a primary diagnosis of obesity; member is 13 years of age or older; documentation that a conservative, medically‑supervised weight‑loss program for at least a 6‑month period within the last 2 years has been unsuccessful; and one of the BMI conditions below is met.

BMI conditions: 1) BMI ≥40 kg/m2; OR 2) BMI ≥35 kg/m2 with at least one serious obesity‑related condition (examples include high risk for Type II diabetes [insulin resistance, prediabetes, metabolic syndrome], osteoarthritis of the knee or hip, improving outcomes of knee or hip replacement, obstructive sleep apnea, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, pseudotumor cerebri, gastroesophageal reflux disease, severe urinary stress incontinence, poorly controlled hypertension on multiple drug therapy); OR 3) BMI >30 kg/m2 with Type II diabetes mellitus inadequately controlled despite optimal medical treatment (including oral or injectable medications, or insulin).

Serious obesity‑related conditions enumerated in policy.

Documentation requirements: Written clinical documentation and supporting information from the attending surgeon must include all of the following: evidence of informed consent; letter from the PCP or appropriate specialist documenting medical necessity, confirmation of nutritionist/dietician evaluation during supervised weight loss, and addressed health‑related behaviors (eg, smoking history/adherence); evidence of participation in a multidisciplinary preoperative program; substance use screening and evidence that harm‑reduction related to substance use was discussed; evidence that risks of nicotine were discussed; evidence vitamin B deficiencies were monitored and treated as needed prior to surgery; evidence the member is free of endocrine disease supported by an endocrine study (T3, T4, blood sugar, and a 17‑Keto Steroid or plasma cortisol); psychological evaluation within the past 6 months by a behavioral health provider addressing psychiatric comorbidities, family/social support, decision‑making capacity, and stability (including absence of active suicidality or significant decompensation); and a complete history and physical including diagnoses, height, weight, BMI, and treatment plan.

Reproductive counseling required for women of childbearing potential with agreement to avoid pregnancy for at least 1 year postoperatively.

Procedures considered experimental or investigational are not covered. Examples specifically enumerated in the policy include endoscopic bariatric and metabolic therapies such as intragastric balloon (IGB), endoscopic sleeve gastroplasty (ESG), and aspiration therapy (AT).

The intended procedure will not be covered if it is determined to be experimental or investigational.

Surgery is contraindicated and therefore not medically necessary for members with a medically correctable cause of obesity. Other contraindications that render bariatric surgery not medically necessary include current or planned pregnancy within one year of the procedure, active suicidality or self-harm, active psychosis, active substance use disorder, ongoing substance abuse within the previous year, severe coagulopathy, uncontrolled or untreated eating disorders, and inability to comply with postoperative long-term follow-up care.

Clinical Thresholds and Pre-Surgery Requirements

inv-05: BMI thresholds

BMI ≥40 kg/m2Qualifies for metabolic and bariatric surgery without additional comorbidity.

BMI ≥35 kg/m2 + comorbidityQualifies when at least one serious obesity-related condition is present (examples: high risk for Type II diabetes, osteoarthritis of knee/hip, obstructive sleep apnea, NAFLD/NASH, GERD, pseudotumor cerebri, severe urinary stress incontinence, poorly controlled hypertension on multiple drug therapy).

BMI >30 kg/m2 + Type II DMQualifies when Type II diabetes mellitus is inadequately controlled despite optimal medical treatment with oral or injectable medications, including insulin.

inv-06: Pre-surgery supervised weight-loss duration

Minimum durationAt least 6 months of a conservative, medically‑supervised weight‑loss program within the last 2 years is required prior to surgery consideration.

DocumentationPCP or specialist letter must document evaluation by a nutritionist/dietician during the supervised weight‑loss program.

Program typeParticipation in a multidisciplinary program to prepare for surgery and extended post‑operative period must be evidenced.

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required when medical necessity criteria are met for metabolic and bariatric surgery. Providers must obtain prior authorization before scheduling surgery and ensure documentation demonstrates the member meets all eligibility requirements (primary diagnosis of obesity, age ≥13, required BMI thresholds, and failure of conservative therapy).

Prior authorization required when ALL medical necessity criteria are met (see coverage criteria).
Ensure prior authorization request includes the full written clinical record listed below.

Documentation Required

Required Clinical Documentation

Providers must submit complete written clinical documentation with the prior authorization request. Documentation from the attending surgeon and referring clinicians must include evidence of informed consent, a complete history and physical (including diagnoses, height, weight, BMI, and treatment plan), and a PCP or specialist letter documenting medical necessity. Additional required materials include nutritionist/dietician evaluation, participation in a multi-disciplinary preparation program, substance use screening and harm-reduction discussion, nicotine risk counseling, preoperative endocrine evaluation and vitamin B monitoring, and a psychological evaluation within the past 6 months addressing psychiatric comorbidities, social support, decision-making capacity, and stability.

Evidence of informed consent.
PCP/specialist letter documenting medical necessity and that nutrition evaluation occurred.
Documentation of participation in a multi-disciplinary pre- and post-operative program.
Substance use screening results and documentation that harm reduction was discussed.
Evidence nicotine risks discussed and vitamin B deficiencies addressed.
Endocrine study (T3, T4, blood sugar, 17-Keto Steroid or Plasma Cortisol).
Psychological evaluation within 6 months: psychiatric diagnoses, family/social support, understanding of procedure, and stability to proceed.

Prior Authorization

Failure of Conservative Therapy Required

A failure of a conservative, medically-supervised weight loss program is required prior to approval for surgery. The member must have participated in such a program for at least 6 months within the last 2 years with documentation that it was unsuccessful.

Conservative, medically-supervised weight loss program ≥6 months within past 2 years and documented unsuccessful outcome.

Denial Risk

Contraindications / Denial Risk

Surgery is contraindicated and should be denied when specific conditions are present. Do not authorize surgery for members with active suicidality or self-harm, active psychosis, active substance use disorder or ongoing substance abuse within the previous year, current or planned pregnancy within one year, medically correctable causes of obesity, severe coagulopathy, uncontrolled/untreated eating disorders, or inability to comply with long-term postoperative follow-up care. Procedures that are experimental or investigational (for example endoscopic bariatric therapies such as intragastric balloon, endoscopic sleeve gastroplasty, or aspiration therapy) are not covered.

Contraindications: medically correctable cause of obesity; current or planned pregnancy within 1 year; active suicidality/self-harm; active psychosis; active substance use disorder; ongoing substance abuse within prior year; severe coagulopathy; uncontrolled/untreated eating disorders; inability to comply with long-term follow-up.
Not covered if experimental/investigational (e.g., IGB, ESG, aspiration therapy).

Definitions

inv-12: BMI — Body Mass Index definition

DefinitionBody Mass Index (BMI) = an individual's weight in kilograms divided by the square of height in meters.

Use in policyBMI thresholds determine medical necessity for metabolic and bariatric surgery (see BMI criteria).

ReportingComplete history and physical must include height, weight, and BMI for authorization documentation.

inv-13: Substance Use Disorder (SUD) — definition

DefinitionSubstance Use Disorder (SUD) = a cluster of cognitive, behavioral, and physiological symptoms indicating continued use of substances despite significant substance‑related problems, encompassing the DSM‑5 drug classes.

Relevance to coverageActive or recent (within prior year) SUD is a contraindication to surgery and may render the procedure not medically necessary.

Screening requirementWritten documentation must include substance use screening results and evidence that harm‑reduction related to substance use was discussed.

inv-14: Behavioral Health Provider — definition

DefinitionBehavioral Health Provider = a provider of behavioral health services, including a psychologist, psychiatrist, or psychiatric nurse practitioner.

Psychological evaluationMember must be evaluated within the past 6 months by the treating behavioral health provider with documentation of psychiatric conditions, support, decision‑making capacity, and stability for surgery.

Evaluation contentEvaluation should address suicidality risk, ability to understand risks/benefits, lifestyle change capacity, adherence to aftercare, and likelihood of decompensation if surgery fails.

OpenPayer

Metabolic and Bariatric Surgery coverage

Coverage Criteria for Metabolic & Bariatric Surgery

Clinical Thresholds and Pre-Surgery Requirements

Prior Authorization and Documentation Requirements

Background

Definitions