CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Digestive Coverage Summary

Defines Neighborhood Health Plan of Rhode Island coverage limits, exclusions, and requirements for digestive system services including bariatric procedures across specified benefit packages; indicates prior authorization and noncoverage of experimental and cosmetic procedures.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDigestive Coverage Summary

Policy CodePolicy N/A

Change TypeClarified (no material change)

Effective Date

Next Review Date

Key ActionObtain medical review and prior authorization for all inpatient hospitalizations for digestive system services.

SourceLink

POLICY UPDATE CHANGES

Version history shows multiple revision and review dates culminating in PEC Revision Date: 10/24/13.

1Laparoscopic Adjustable Gastric Banding per lifetime

1Gastric Bypass procedures per lifetime

5Bariatric procedures not covered

5Benefit packages named

Coverage Summary

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Digestive system services encompass a broad range of surgical procedures. Members and providers should refer to the Transplant benefit coverage summary for transplant information, the Dialysis benefit coverage summary for peritoneal dialysis, and the Outpatient Surgery & Procedure Benefit Coverage Summary for common outpatient procedures such as endoscopy and colonoscopy. This policy defines coverage limits, exclusions, and requirements for digestive system services including bariatric procedures and notes prior authorization and other coverage constraints.

Key Statistics

Laparoscopic Adjustable Gastric Banding per lifetime1

Gastric Bypass procedures per lifetime1

Bariatric procedures listed as not covered5

Benefit packages named5

Medical Necessity Criteria

General Coverage and Limitations

Covered when ALL of the following are met:

ALL of the following

Service scope: Service is a digestive system service (broad range of surgical services and procedures involving the digestive system).
Covered benefit packages: Member is in a covered benefit package: RIte Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, or Rhody Health Options Phase One.
Prior authorization: All inpatient hospitalizations require medical review and prior authorization.
Prior authorization is required for all inpatient hospitalizations.
Experimental/non-FDA: Service is not experimental or non-FDA approved, except experimental/non-FDA approved services may be covered when used in the treatment of cancer.
Experimental/non-FDA services otherwise not covered; exception for cancer treatment.
Cosmetic exclusion: Service is not cosmetic surgery or procedure.
Cosmetic surgery and procedures are not covered.

Bariatric Surgery - Lifetime Limits

Bariatric surgical procedures are covered only under the following lifetime limits:

ALL of the following

Laparoscopic Adjustable Gastric Banding: When medical necessity criteria are met, one (1) Laparoscopic Adjustable Gastric Banding allowed per lifetime.1 per lifetime
Documentation must support medical necessity; see provider requirements for documentation linkage.
Gastric Bypass: One (1) Gastric Bypass procedure is allowed per lifetime.1 per lifetime
Coverage after failed procedure: Gastric bypass procedure may be covered if medically necessary after failed laparoscopic procedure.

Bariatric Surgery - Not Covered Procedures

The following bariatric surgical procedures are NOT covered per Neighborhood's Clinical Medical Policy Bariatric Surgery:

Not covered procedures

Open adjustable gastric banding
Sleeve gastrectomy: Open and laparoscopic sleeve gastrectomy
Vertical banded gastroplasty: Open and laparoscopic vertical banded gastroplasty
Gastric Balloon
Intestinal Bypass

Exclusions - Member Type

EFP exclusion: Extended Family Planning (EFP) members are excluded from this benefit; EFP members do not have a comprehensive benefit package.

Provider Actions

Prior Authorization

Prior authorization for inpatient hospitalizations

All inpatient hospitalizations for digestive system services require medical review and prior authorization.

Documentation Required

Bariatric procedure medical necessity and lifetime allowance

Documentation must support medical necessity for bariatric procedures. When medical necessity criteria are met, coverage is limited to one (1) laparoscopic adjustable gastric banding per lifetime and one (1) gastric bypass procedure per lifetime.

Denial Risk

Experimental/non-FDA and cosmetic exclusions

Claims for experimental or non‑FDA approved services are not covered (except when used in the treatment of cancer). Cosmetic surgeries and procedures are not covered and may be denied.

Definitions & Background

Digestive system services are defined as a broad range of surgical services and procedures involving the digestive system. Covered benefit packages include RIte Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, and Rhody Health Options Phase One.

Definitions: Digestive system services — broad range of surgical services and procedures involving the digestive system. EFP (Extended Family Planning) — members excluded from the comprehensive benefit package and therefore excluded from this benefit.

OpenPayer

Digestive Coverage Summary

Coverage Summary

Medical Necessity Criteria

Provider Actions

Coding

Definitions & Background

Revision History