CurrentTexas Children's Health PlanPolicy 6174

Bariatric Surgery Authorization and Medical Necessity

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This guideline governs prior authorization and medical necessity review for bariatric surgery requested for Texas Children's Health Plan members. It establishes required clinical documentation, facility standards, contraindications, repeat-surgery criteria, and exclusions.

Policy Summary

PayerTexas Children's Health Plan

PolicyBariatric Surgery Authorization and Medical Necessity

Policy CodePolicy 6174

Change TypeNo material change

Effective DateJan 23, 2023

Next Review DateN/A

Key ActionSubmit prior authorization for all bariatric surgery requests to the Utilization Management Department.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All requestsBariatric surgery requests require authorization

ExcludedGastric weight-loss procedures are excluded for CHIP and CHIP Perinate

>50% excess body weightAdequate success threshold two years after primary surgery for possible conversion

Texas facilityBariatric surgery must be performed at an eligible Texas facility

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CurrentTexas Children's Health PlanPolicy 6174

Bariatric Surgery Authorization and Medical Necessity

Customize your policy alerts

Sign up for texaschildrenshealthplan Policy 6174 alerts

Get alerted when Policy 6174 changes without checking for updates manually.

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Policy Summary

PayerTexas Children's Health Plan

PolicyBariatric Surgery Authorization and Medical Necessity

Policy CodePolicy 6174

Change TypeNo material change

Effective DateJan 23, 2023

Next Review DateN/A

Key ActionSubmit prior authorization for all bariatric surgery requests to the Utilization Management Department.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All requestsBariatric surgery requests require authorization

ExcludedGastric weight-loss procedures are excluded for CHIP and CHIP Perinate

>50% excess body weightAdequate success threshold two years after primary surgery for possible conversion

Texas facilityBariatric surgery must be performed at an eligible Texas facility

Bariatric Surgery Medical Necessity

Initial Bariatric Surgery

Bariatric surgery is covered when prior authorization is obtained and the requesting physician documents that ALL applicable criteria are met. InterQual criteria will be used to establish medical necessity.

ALL of the following

Unsuccessful medical treatment for obesity.
Psychiatric profile indicating the candidate is able to understand, tolerate, and comply with all phases of care, is committed to long-term follow-up requirements, and has appropriate post-operative expectations addressed.
Completed preoperative mental health assessment by a mental health professional deeming the member an acceptable candidate if the member has a history of psychiatric or psychological disorders, is under the care of a mental health professional, or is taking psychotropic medications.
Thorough explanation of the risks, benefits, and uncertainties of the procedure.
Treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling.
Treatment plan includes counseling regarding exercise and psychological issues, and the availability of supportive resources when needed.
Referral to the bariatric surgeon was completed by the practitioner treating the member's comorbid condition(s).
The facility where services will be provided is in Texas and is either accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) or is a children's hospital with a bariatric surgery program that provides access to an experienced surgeon and a team capable of long-term follow-up of the member's and family's metabolic and psychosocial needs.
NONE of the following contraindications may be present
- Endocrine cause for obesity, inflammatory bowel disease, chronic pancreatitis, cirrhosis, portal hypertension, or abnormalities of the gastrointestinal tract.
- Chronic, long-term steroid treatment.
- Pregnancy or plans to become pregnant within 18 months.
- Noncompliance with medical treatment.
- Significant psychological disorders that would be exacerbated by or interfere with long-term management after the operation.
- Active malignancy.

Repeat Bariatric Surgery

Repeat bariatric surgery may be considered medically necessary when either of the following criteria is met.

ONE of the following

Repeat surgery is needed to correct complications from prior bariatric surgery, such as band malfunction, obstruction, or stricture.
ALL of the following
- Repeat surgery is needed to convert to a Roux-en-Y gastroenterostomy or to correct pouch failure.
- The member is otherwise compliant.
- The initial bariatric surgery met medical-necessity criteria.

Roux-en-Y Gastroenterostomy Conversion

Conversion to a Roux-en-Y gastroenterostomy may be considered medically necessary when ALL of the following criteria are met.

ALL of the following

The member has not had adequate success two years following the primary bariatric surgery procedure, defined as a loss of more than 50 percent of excess body weight.2 years following primary surgery
The member has been compliant with a prescribed nutrition and exercise program following the procedure.

Gastric procedures for weight loss are excluded from the benefit for CHIP and CHIP Perinate.

Bariatric surgery is not medically necessary when the primary purpose of the surgery is weight loss for its own sake, cosmetic purposes, psychological dissatisfaction with personal body image, or the member's or provider's convenience or preference.

Clinical Thresholds and Contraindications

Adequate success after primary bariatric surgery

Adequate success thresholdLoss of more than 50 percent of excess body weight

Measurement pointTwo years following the primary bariatric surgery procedure

ApplicationFailure to achieve this threshold may support consideration of conversion to a Roux-en-Y gastroenterostomy when the member has complied with the prescribed nutrition and exercise program

Pregnancy planning contraindication

ContraindicationPregnant

Pregnancy planningPlans to become pregnant within 18 months

Requirement

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for all bariatric surgery. Requests are submitted to the Utilization Management Department through online submission, fax, phone, or mail and are processed during normal business hours.

Submit all requests through an approved TCHP Utilization Management channel.

Prior Authorization

Separate Authorization for Postoperative Inpatient Care

Inpatient services needed following bariatric surgery, other than observation-level care, require a separate authorization request.

Postoperative inpatient services beyond observation are not covered under the bariatric surgery authorization automatically.

Bariatric Surgery Overview

Bariatric surgery comprises surgical weight-loss procedures that modify the anatomy of the digestive system to treat medical conditions caused or significantly worsened by obesity and related comorbidities. Surgery is considered when obesity has not been adequately treated with standard measures without significant weight loss and the member can participate in long-term medical, nutritional, and psychosocial follow-up.

Bariatric Surgery Definition

Bariatric Surgery

Procedure typeSurgical weight loss procedures

Anatomical effectModify the anatomy of the digestive system

Clinical indicationTreat medical conditions caused or significantly worsened by obesity and comorbid conditions

Standard-treatment criterionConditions cannot be adequately treated by standard measures unless significant weight loss occurs

Policy Summary

PayerTexas Children's Health Plan

PolicyBariatric Surgery Authorization and Medical Necessity

Policy CodePolicy 6174

Change TypeNo material change

Effective DateJan 23, 2023

Next Review DateN/A

Key ActionSubmit prior authorization for all bariatric surgery requests to the Utilization Management Department.

SourceLink

On This Page

None of the listed additional contraindications may exist

Authorization Is Not a Guarantee of Benefits

Preauthorization is based on medical necessity and does not guarantee benefits or eligibility. Approval applies only to the medical necessity of the treatment or service; benefit limitations, exclusions, and applicable regulatory requirements still apply.

Services remain subject to benefit limitations and exclusions.
Failure to comply with state or federal requirements may result in retrospective audit and potential financial recoupment.

Documentation Required

Required Clinical and Psychosocial Documentation

The requesting physician must submit documentation supporting all applicable bariatric surgery criteria and the member’s readiness for treatment.

Unsuccessful medical treatment for obesity.
Psychiatric profile showing the candidate can understand, tolerate, and comply with all phases of care and is committed to long-term follow-up.
Documentation that postoperative expectations have been addressed.
Completed preoperative mental health assessment by a mental health professional when the member has a psychiatric or psychological history, is under mental-health care, or takes psychotropic medication.
Thorough explanation of the procedure’s risks, benefits, and uncertainties.
Treatment plan covering pre- and postoperative dietary evaluations and nutritional counseling.
Counseling regarding exercise, psychological issues, and available supportive resources.
Referral to the bariatric surgeon by the practitioner treating the member’s comorbid condition(s).

Prior Authorization

Facility Eligibility

The requesting physician must identify the facility and attest that services will be provided at an eligible facility in Texas.

Facility accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP); or
Children’s hospital with a bariatric surgery program, access to an experienced surgeon, and a team capable of long-term follow-up of the member’s and family’s metabolic and psychosocial needs.

Unsupported block type: denial_risk

Denial Risk

Contraindications

The physician must document that none of the following contraindications are present before authorization can be supported.

Endocrine cause for obesity, inflammatory bowel disease, chronic pancreatitis, cirrhosis, portal hypertension, or gastrointestinal-tract abnormalities.
Chronic, long-term steroid treatment.
Pregnancy or plans to become pregnant within 18 months.
Noncompliance with medical treatment.
Significant psychological disorders that could be exacerbated or interfere with long-term postoperative management.
Active malignancy.

Unsupported block type: denial_risk