Currentpriority healthPolicy N/A

Bariatric Surgery authorization form

A prior authorization request form and checklist used by Priority Health to document medical necessity criteria, contraindications, required evaluations, and member/provider data for authorization of bariatric surgical procedures (primary and revisional). It references Medical Management of Obesity policy #91594 for specific medical management program criteria and documentation.

Policy Summary

Payerpriority health

PolicyBariatric Surgery authorization form

Policy CodePolicy N/A

Change TypeNo material change reported

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed bariatric surgery prior authorization form to 888.647.6152 including member demographics, BMI with date measured (within one month), selected CPT code for requested procedure, documentation of medical management program participation, and required evaluations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were reported for this update.

3BMI eligibility pathways

6Common contraindications listed

4Procedure categories listed

Coverage Summary

This prior authorization request form and checklist is used by Priority Health to document medical necessity criteria, contraindications, required evaluations, and member/provider data for authorization of bariatric surgical procedures (both primary and revisional procedures).