CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Bariatric Bypass Surgery Prior Authorization Form / Coverage Criteria

Form and submission requirements for requesting prior authorization of bariatric bypass surgery for Neighborhood Health Plan of Rhode Island members; applies to providers submitting authorization requests.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBariatric Bypass Surgery Prior Authorization Form / Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and return the prior authorization form with required clinical and administrative fields, including physician signature, to Utilization Management for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1prior authorization form

physiciansignature requirement

UM phone/faxsubmission contact

member/provider/clinicalform sections

Coverage Criteria and Authorization Requirements

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Form completion required for authorization review

Authorization requires completion of the following clinical and administrative fields on the Bariatric Bypass Surgery Prior Authorization Form to permit coverage review; refer to Neighborhood's Clinical Medical Policy for detailed medical necessity criteria.

Form completion requirements

Member identifiers: Member's Name, Member ID #, Member DOB.
Provider identifiers: Provider's Name, Supplier ID or NPI #, Date of Request, Date of Service, Previous Authorization # (if applicable), Place of Service (city/facility) and contact information.
Requested procedure and diagnosis: CPT code(s) and units (inpatient and/or outpatient as applicable), Diagnosis and Diagnosis Code.
Clinical measurements: Current BMI, Height, Weight.
Clinical impact and comorbidities: Describe impact on Activities of Daily Living; describe co-morbid or other health conditions; list any current psychiatric/psychosocial co-morbidities and treatment in place.
Conservative therapy documentation: Describe medically supervised weight loss attempts in the last 6 months.
Functional and capacity assessments: Comment on demonstrated ability to comply with medical regimen; comment on ability to understand risk of gastric bypass surgery.
Signature: Signature of treating physician and Date (physician signature required).

Provider Submission Steps and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for bariatric bypass surgery. Submit the completed Bariatric Bypass Surgery Prior Authorization Form to Utilization Management with all required fields. Incomplete submissions may delay review.

Return completed form to Utilization Management at (401) 459-6023
Refer to Neighborhood's Clinical Medical Policy at www.nhpri.org for coverage criteria

Documentation Required

Conservative Therapy Documentation

Document medically supervised weight loss attempts within the past 6 months. Include duration, program type, frequency of visits, specific interventions (diet, exercise, pharmacotherapy), and weight change achieved.

Describe medically supervised weight loss attempts in last 6 months (program name, start/end dates, adherence, results)
Include objective measures such as documented weight/BMI changes and clinician notes

Documentation Required

Required Form Fields and Signature

The form must contain complete member, provider, and clinical information and be signed by the treating physician. Missing fields or absent signature will result in an incomplete submission.

Member fields: Member's Name, Member's ID #, Member's DOB
Provider fields: Provider's Name, Supplier ID or NPI #, Date of Request, Date of Service, Previous Auth # (if applicable), Place of Service/Facility, Provider's Phone #, Provider's Fax #, Provider's Contact Name
Clinical fields: Inpatient/Outpatient CPT Code(s) and Units, Diagnosis and Diagnosis Code, Current BMI, Height, Weight, Description of impact on Activities of Daily Living, Co-morbid conditions, Weight loss attempt details, Ability to comply with medical regimen, Psychiatric/psychosocial co-morbidities and treatments, Comment on ability to understand surgical risks
Signature requirement: Signature of Treating Physician and Date (NOTE: THIS FORM MUST BE SIGNED BY A PHYSICIAN)

Note

Submission Instructions

Return the completed form to the Utilization Management Department and include any supporting clinical documentation (labs, consult notes, prior weight-history). Contact UM for questions or to verify receipt.

Mail/fax/phone submissions: Utilization Management Department (401) 459-6023
Include supporting documentation: clinician notes, weight history, lab results, psychiatric evaluation if applicable

Denial Risk

Payment/Approval Not Guaranteed

Authorization is not a guarantee of payment. Even if an authorization number is issued, payment is subject to member eligibility, benefits, and claim review. If not approved, a Not Approved letter will be sent.

Authorization #, Dates of Service, Services Approved will be communicated if authorized
Not Approved - Letter to Follow

Background and Purpose

This form is used to request prior authorization for bariatric bypass surgery. It collects required member and provider identifiers and targeted clinical measures to support a medical necessity review, including fields for requested CPT and diagnosis codes, current BMI, height, weight, and a description of the impact on activities of daily living and co-morbid conditions.

The form also documents prior conservative management: providers must report medically supervised weight loss attempts in the last 6 months and provide psychiatric/psychosocial history and an assessment of the member’s ability to understand surgical risk. The treating physician’s signature and date are required to complete the request.

Return the completed form to the Utilization Management Department as instructed on the form; the payer’s Clinical Medical Policy (available on the website) contains the detailed coverage criteria that this authorization request supports.

Key Definitions and Clinical Data Elements

Current BMI (form field)

Field nameCurrent BMI

Location on formListed under clinical data: 'Current BMI:' alongside Height and Weight fields.

UseReport numeric BMI value to support eligibility and medical necessity determinations.

Medically supervised weight loss attempts — required documentation

Documentation requiredProvide a description of medically supervised (non-surgical) weight loss attempts undertaken within the last 6 months.

Form promptUse the exact form entry: 'Describe medically supervised weight loss attempts in last 6 months:'

ContextIncluded with other clinical data (BMI, height, weight, comorbidities) to support prior authorization review.

OpenPayer

Bariatric Bypass Surgery Prior Authorization Form / Coverage Criteria

Coverage Criteria and Authorization Requirements

Procedure, Diagnosis, and Clinical Coding

Provider Submission Steps and Documentation Requirements

Background and Purpose

Key Definitions and Clinical Data Elements

CPT Code	Field for inpatient CPT code(s) as requested on form
CPT Code	Field for outpatient CPT code(s) as requested on form
Diagnosis Code	ICD-10 diagnosis code field