Obesity and Morbid Obesity Management

Transcription

1 Rule Category: Medical ` Ref: No: 2011-MN-0022 Version Control: Version No. 4.0 Effective Date: November 2011 Revision Date: August-2015 Obesity and Morbid Obesity Management Adjudication Rule Table of content Abstract Page 1 Scope Page 2 Adjudication Policy Page 2 Adjudication examples Page 3 Denial codes Page 4 Appendices Page 4 Abstract For Members Obesity is an excess proportion of total body fat. A person is considered obese when his or her weight is 20% or more above normal weight. The most common measure of obesity is the body mass index or BMI. A person is considered overweight if his or her BMI is between 25 and 29.9; a person is considered obese if his or her BMI is over 30. Morbid obesity" means that a person is either 50%-100% over normal weight, more than 100 pounds over normal weight, has a BMI of 40 or higher, or is sufficiently overweight to severely interfere with health or normal function. Weight can be controlled by life style modification or medications or curbed by different surgical modalities available. Weight loss management modalities like dietician consultations, medications and surgeries are covered by Daman only for those health insurance plans with the specific benefit. For Medical Professionals This guideline addresses the coverage of all modalities of conservative and surgical management for obesity and morbid obesity for all health insurance plans administered by Daman. Daman covers dietician services for weight control in obesity and surgical management of morbid obesity for those health insurance plans with the specific benefit. Criteria for eligibility of medical / conservative management or weight loss surgery (as given in the Adjudication rule) should be met in order for it to be covered. Approved by: Daman Responsible: Medical Strategy & Development Department Related Adjudication Rules: None Disclaimer By accessing these Daman Adjudication Rules (the AR ), you acknowledge that you have read and understood the terms of use set out in the disclaimer below: The information contained in this AR is intended to outline the procedures of adjudication of medical claims as applied by the National Health Insurance Company Daman PJSC (hereinafter Daman ). The AR is not intended to be comprehensive, should not be used as treatment guidelines and should only be used for the purpose of reference or guidance for adjudication procedures and shall not be construed as conclusive. Daman in no way interferes with the treatment of patient and will not bear any responsibility for treatment decisions interpreted through Daman AR. Treatment of patient is and remains at all times the sole responsibility of the treating Healthcare Provider. This AR does not grant any rights or impose obligations on Daman. The AR and all of the information it contains are provided "as is" without warranties of any kind, whether express or implied which are hereby expressly disclaimed. Under no circumstances will Daman be liable to any person or business entity for any direct, indirect, special, incidental, consequential, or other damages arising out of any use of, access to, or inability to use or access to, or reliance on this AR, including but without limitation to, any loss of profits, business interruption, or loss of programs or information, even if Daman has been specifically advised of the possibility of such damages. Daman also disclaims all liability for any material contained in other websites linked to Daman website. This AR is subject to the laws, decrees, circulars and regulations of Abu Dhabi and UAE. Any information provided herein is general and is not intended to replace or supersede any laws or regulations related to the AR as enforced in the UAE issued by any governmental entity or regulatory authority, or any other written document governing the relationship between Daman and its contracting parties. This AR is developed by Daman and is the property of Daman and may not be copied, reproduced, distributed or displayed by any third party without Daman s express written consent. This AR incorporates the Current Procedural Terminology and Current Dental Terminology (CPT and CDT, which is a registered trademark of the American Medical Association ( AMA ), and the American Dental Association ( ADA ) respectively), and the CPT and CDT codes and descriptions belong to the AMA. Daman reserves the right to modify, alter, amend or obsolete the AR at any time by providing one month prior notice. Doc Ctrl No.: TEMP/MSD-008 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 1 of 7

2 Scope This guideline addresses the coverage of all modalities of conservative and surgical management for obesity and morbid obesity for all plans administered by Daman as per the policy terms and conditions. Obesity is defined as abnormal or excessive fat accumulation that may impair health. Body mass index (BMI) is a simple index of weightfor-height that is commonly used to classify obesity in adults. It is defined as a person's weight in kilograms divided by the square of his height in meters (kg/m2). The WHO definition of Obesity is BMI greater than or equal to 30 kg/m2. The BMI categories are as follows: Category Adults (kg/m 2 ) BMI Children between the ages of 2 and 19 years (percentile for age and gender) Underweight < th percentile Normal weight th 84th percentile Overweight th < 95th percentile Obesity th percentile Morbid obesity 40 Adjudication Policy Eligibility / Coverage Criteria Daman covers conservative management for weight control in obesity for only those health insurance plans with the specific benefit. Coverage of surgical management of morbid obesity is limited to those health insurance plans with the specific benefit and as per the coverage mentioned in SOB of each plan. Criteria for eligibility of conservative management of obesity: BMI > 30 OR BMI and Waist circumference: > 88 cm (Females) > 102 cm (Males) and 2 or more co-morbidities Criteria for eligibility of weight loss surgery for morbid obesity for Adults (> 18 years): Please refer to table 1 on page no 4 Criteria for eligibility of weight loss surgery for morbid obesity for young Adults (postpubertal - 18 years): Please refer to table 1 on page no 4 Preoperative workup for bariatric surgery Please refer to table 2 on page no 7 The major comorbidities which evidence suggests can be improved by losing weight include: 1. Type 2 Diabetes 2. Non-alcoholic steatohepatitis (NASH)/ Hepaticatosis (fatty liver disease) 3. Lymphoedema 4. Hypercholesteraemia or High triglyceride- count if patient already has one severe comorbidity and BMI>40 5. Sleep Apnea requiring continuous positive airway pressure (CPAP) 6. Immediate Family history of heart disease and patient s CVD risk >20% 7. Hypertension counts only if the patient meets one of the following criteria: a. Requiring three antihypertensive drugs to control hypertension b. Taking three antihypertensive drugs but hypertension not controlled c. Taking fewer than three antihypertensive drugs, hypertension not controlled (>140/90), and unable to increase antihypertensive medication further due to clear contraindication or proven poor tolerance of additional medications 8. Asthma counts only if the patient meets at least one of the following criteria: a. Attended ED within the last year with acute asthma exacerbation b. Any previous admission to hospital ward with acute asthma exacerbation c. Any previous asthma exacerbation judged near-fatal d. Currently requiring significant corticosteroid treatment ongoing inhaled corticosteroid treatment (i.e. BTS Step 2), or more than two courses of oral corticosteroid treatment in the last year e. Currently requiring three or more classes of asthma medication (i.e. BTS Step 3) f. Brittle asthma g. If asthma impedes the patient s ability to exercise to support weight loss Doc Ctrl No.: TEMP/MSD-008 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 2 of 7

3 Joint Strategy for weight loss & risk factor control: 1. Lifestyle Modification a) Diet: kcal/day reduction b) 30% or less total kcal from fat c) ~ 15% total kcal from protein d) 55% of total kcal from CHO e) Physical Activity: Initially, minutes of moderate activity, 3-5 times a week; Eventually 30 minutes of moderate activity on most days 2. Behavior Therapy 3. Pharmacotherapy Adjunct to lifestyle therapy; consider if patient has not lost 1 lb/wk (approximately 0.5 Kg) after 6 months of lifestyle therapy. a) Orlistat -120 mg po tid before meals 4. Bariatric (weight loss surgery) Should only be undertaken by a specialist and may not be available in all countries. Consider if other weight loss attempts have failed. a) Gastric bypass b) Gastric banding c) Sleeve gastrectomy Followed by life-long medical monitoring. Requirements for Coverage ICD and CPT codes must be coded to the highest level of specificity. Non-Coverage 1. Treatment of obesity is not covered for those health insurance plans where it is a general exclusion of their respective policies. 2. Coverage will be restricted as per SOB for the plans in which obesity treatment coverage is restricted, regardless of the associated comorbidities or failed treatment attempts e.g.; gastric banding for morbid obesity only. 3. Coverage for types of bariatric surgeries will be restricted as per SOB Payment and Coding Rules Please apply HAAD payment rules and regulations and relevant coding manuals for ICD, CPT, etc. 1. Obesity or morbid should be coded with the appropriate ICD 9 CM codes ( or ) designated as the principal diagnosis. 2. The principal code for obesity or morbid obesity should be accompanied by a secondary diagnosis code that defines the patient s BMI (V85.30 V85.39, V85.4 or V85.54) 3. In case pre-op tests are required for bariatric surgery 3 ICD codes are required i.e., pre-op V-code, Obesity code and BMI code 4. Weight loss attempts should have been delivered by a HAAD licensed specialist 5. All patients should have received counseling from a multi disciplinary specialist team including as minimum a specialist physician or nurse, a specialist nutritionist and specialist psychologist, who should perform a risk benefit analysis. 6. Bariatric Surgery should only be undertaken by a consultant level surgeon with expertise in the field of bariatric surgery Adjudication Examples Example 1 Question: A 28 year old male patient holding Premier plan was diagnosed with obesity (BMI: 35.5 kg/m2). He was advised to undergo sleeve gastrectomy. Will this service be covered for this patient? Answer: No, sleeve gastrectomy will not be covered for this patient, as surgical treatment for obesity for this member is restricted to gastric banding only if medically necessary. The service would hence be rejected with the denial code NCOV-003. Example 2 Question: A 34 year old female patient holding Thiqa plan, diagnosed with morbid obesity (BMI: 43.3 kg/m2), was advised to undergo bariatric surgery. Will the service be covered for this patient? Answer: yes, the service will be covered for this patient if there is evidence of failed weight loss attempts for 6 months. Denial codes Code NCOV-001 NCOV-003 MNEC-004 CLAI-012 Code description Diagnosis(es) is (are) not covered Service(s) is (are) not covered Service is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities Submission not complaint with contractual agreement between provider & payer Doc Ctrl No.: TEMP/MSD-008 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 3 of 7

4 MNEC-003 BENX-002 AUTH-001 AUTH-005 Service is not clinically indicated based on good clinical practice Benefit maximum for this time period or occurrence has been reached Prior approval is required and was not obtained Claim information is inconsistent with pre-certified/authorized services Laparoscopic Bariatric Surgery. Available: uidelines-for-clinical-application-oflaparoscopic-bariatric-surgery/. Last accessed 20th April, B. Revision History Date Change(s) V 3.0: New template Appendices A. References 1. CDC (US) BMI centile charts available at s.htm 7. General exclusion lists 8. HAAD Standard for diagnosis, management and data reporting of interventions for weight management and obesity 9. Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. NICE clinical guideline 43, Dec Obesity - The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults National Institute of Health, USA, Sarah E. Barlow and the Expert Committee (Pediatrics 2007), Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Available on line at /120/Supplement_4/S Schedule of benefits. 13. AACE/TOS/ASMBS. (2013). Clinical Practice Guidelines for the Pre-operative nutritional, metabolic and non-surgical support of Bariatric surgery patient. Bariatric surgery Clinical Practice Guidelines. 2 (1), p SAGES (Society of American Gastrointestinal and Endoscopic Surgeons). (March, 2008). Guidelines for Clinical Application of V Restored original effective date 3. Disclaimer updated as per system requirements 4. AR content updated as per latest HAAD standard 5. Pre-op investigations for bariatric surgery added. Doc Ctrl No.: TEMP/MSD-008 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 4 of 7

5 Table 1: Criteria for eligibility and documented evidence for approvals for Bariatric Surgery: (3) Criterion Requirements Documentary evidence Adults (>18 years) Clinical Indicators Weight Loss attempts Service / consultation 1. BMI > 50 kg/m 2 (no co morbidities or evidence of failed noninvasive interventions are necessary); OR 2. BMI kg/m 2 with evidence of failed non-invasive interventions, weight loss and pharmacotherapy (no comorbidities are necessary) OR 3. BMI kg/m 2 with evidence of failed non-invasive interventions, weight loss and pharmacotherapy and at least 2 comorbidities* OR 4. BMI kg/m 2 with evidence of failed non-invasive interventions, weight loss and pharmacotherapy and at least 3 comorbidities*. Physicians seeking to perform bariatric surgery for patients in the kg/m 2 category must provide evidence of non-invasive interventions, weight loss and/or pharmacotherapy which is being delivered by a physician specializing in weight/obesity management or a qualified member of their multidisciplinary team who has qualification in cognitive behavioural therapy. No-invasive interventions (lifestyle and medication) must be evidenced over a minimum period of six months. 1. Six months of lifestyle modification using a comprehensive, structured program has not resulted in an average weight loss 0.5Kg/week over 6months; and 2. Six months of pharmacotherapy using first line therapies has not resulted in weight loss 0.5kg/week 1. Weight loss attempts must have been delivered by a HAAD licensed professional specialising in weight management. 2. All patients must have received counselling from a multidisciplinary specialist team including as a minimum a physician specialising in weight management or nurse, a HAAD Licensed dietician and psychologist, who should perform a risk-benefit analysis. 3. Bariatric Surgery must only be undertaken by a consultant level surgeon with expertise in the field of bariatric surgery and in accordance with the requirements of this standard (Appendix 3). 4. The consent process must be undertaken by the consultant level bariatric surgeon or a specialist level bariatric surgeon under the supervision of a consultant level surgeon; risks and benefits must be fully explained, including the short, medium and long term risks. Signed consent must be kept on patient records (HAAD Consent Policy). 5. The bariatric centre must offer follow-up post-surgery with a multi-disciplinary team including as a minimum a specialist bariatric surgeon, a nurse, a dietician and a support group, all with specialisation in bariatric procedures and interventions. 1. Medical report including: measure of height, weight and BMI personal medical history family history of cardiovascular disease (CVD) blood pressure lipid profile diabetes screen formal CVD risk score HbA1c waist hip ratio sleep study (if indicated) 1. Report from a HAAD licensed dietician 2. Evidence of the delivery of a structured program for lifestyle modification 1. Physician / nurse license number to be checked against HAAD database 2. Report from HAAD Licensed Dietician 3. Report of support from a psychologist 1. Report from the consultant level bariatric surgeon with justifications of the requirement for bariatric surgery. 2. The signed consent form including evidence of explanation of risks and benefits of bariatric surgery in line with the HAAD Consent Policy available at HAAD website 3. Evidence of the designated specialised bariatric team who will undertake post-surgery follow-up Young adults (post-pubertal 18 years) Clinical Indicators BMI 99 th Centile or BMI > 40; AND There is evidence of comorbidity including but not limited to: insulin resistance, hypertension, sleep apnea, dyslipidemia, or pseudotumor cerebrii; AND There is a significant health risk as a direct result of the obesity. Inclusion criteria (must meet all): 1. Young adult candidates for bariatric surgery should be morbidly obese (defined by the World Health Organisation as a body mass index >40) AND 2. have comorbidities related to obesity that might be remedied with durable weight loss AND 3. Have attained a majority of skeletal muscle (generally greater than 13 years of age for girls and 15 years of age for boys) AND 4. Be at Tanner development stage 4 or greater AND 5. Have a history of obesity for at least 3 years including documented failed attempts and diet and medical 1. Medical report / pre-operation assessment including: measure of height, weight and BMI exclusion of a primary cause for the obesity including endocrine and genetic disorders family history of cardiovascular disease (CVD) family history of obesity lipid profile diabetes screen fasting glucose and HbA1c liver function tests complete blood count thyroid function tests screening for micronutrients Doc Ctrl No.: TEMP/MSD-008 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 5 of 7

6 management of obesity over at least 6 months AND 6. All other attempts at behaviour modification have failed to achieve weight loss goals over a six month period AND 7. Express willingness to follow program requirements which include signing an assent form, having the individual s legal guardian sign a consent form; completing 1-2 week, 6 week, 3 month, 9 month, 12 month, and every month follow up visits for a total of five years, and completing all clinically required laboratory and diagnostic tests AND 8. Agreed to avoid pregnancy for a year post operatively AND 9. Agreed to adhere to nutritional guidelines postoperatively AND 10. Has a supportive family environment AND 11. Confirmation by a senior clinical psychologist with child/adolescent experience or consultant/specialist psychiatrist with child/ adolescent experience that the subject is sufficiently emotionally mature to comply with the clinical protocol and fully understands the short, medium and long term implications of the surgery. Sleep study for patients with symptoms of obstructive sleep apnoea. bone age assessment considered for younger patients to document the degree of skeletal maturity cardiac and pulmonary evaluation endocrine evaluation gastro oesophageal reflux disease Other tests if relevant (e.g. pregnancy). Evidence of the delivery of a structured program for lifestyle modification Weight Loss attempts Exclusion criteria: 1. History of clinical disease that may prohibit weight loss surgery, including, but not limited to: congenital or acquired intestinal telangiectasia; Crohn's disease or ulcerative colitis; severe cardiopulmonary disease or severe coagulapathy; hepatic insufficiency or cirrhosis. 2. Presence of dysphagia or documented esophageal dysmotility. 3. Patients with autoimmune connective tissue disorders. 4. Pregnancy or intention of becoming pregnant in the next 12 months. 5. Presence of uncontrolled psychiatric disease or patient immaturity which would compromise cooperation with the clinical protocol. 6. Chronic use of aspirin and/or non-steroidal antiinflammatory medications and unwillingness to discontinue the use of these concomitant medications. 7. Unwillingness to discontinue use of weight loss medications after surgery. 8. Unwillingness to Comply with clinical protocol. Six months of a comprehensive, structured multi-disciplinary protocol including a structured behaviour modification programme** 1. Report from a HAAD Licensed dietician 2. Evidence of the delivery of a structured program for lifestyle modification Service / consultation 1. Weight loss attempts must have been delivered by a HAAD licensed specialist. 2. The child must have had consultation and counselling from a multi-disciplinary team with expertise in childhood obesity, including as a minimum a HAAD licensed dietician, child psychologist, paediatrician and a paediatric bariatric surgeon. 3. The assessment for surgery (or medication) must only be made by a consultant level paediatric bariatric surgeon. 4. The consent process must be undertaken by the consultant level paediatric bariatric surgeon and risks and benefits fully explained, including the short, medium and long terms risks. 5. The bariatric centre must offer follow-up post-surgery with a multi-disciplinary team including as a minimum a specialist paediatric bariatric surgeon, a specialist paediatric bariatric nurse, a specialist paediatric bariatric dietician and a specialist paediatric bariatric support group. 1. Physician / nurse license number to be checked against HAAD database 2. Report from a HAAD Licensed dietician with child/ adolescent experience 3. Report from paediatric consultant psychological support 4. Report from a consultant paediatric bariatric surgeon with justifications of the requirement for surgery 5. The signed consent form including evidence of explanation of risks and benefits of bariatric surgery in line with the HAAD consent policy available at HAAD website 6. Evidence of the designated paediatric specialist bariatric team who will undertake post-surgery follow-up **In accordance with HAAD Standards for diagnosis, management and data reporting for weight management and obesity Doc Ctrl No.: TEMP/MSD-008 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 6 of 7

7 Table 2: Pre-Operative investigations specifically for Bariatric surgery (8, 9,10) Category Test Indication Frequency Additional Info Glucose Calcium Urea, creatinine ALT, AST Urine analysis tests Coagulation profile Blood group & type (as per HAAD VQ 2012; included in blood transfusions if done during or after the surgery) general preops. Can be done before surgery N.A CBC ECG Cardiopulmonary evaluation CXR Echocardiography Only if cardiac disease or pulmonary hypertension suspected Once throughout the pre-bariatric surgery decision and work-up Total Protein lipid profile ultrasound To detect liver and gall bladder abnormalities Pre-op if not done in last 30 days N.A Psychiatric counseling Once throughout the pre-bariatric surgery decision and work-up GI evaluation Upper GI endoscopy Only before bypass surgery, if suspicion of gastric pathology Once throughout the pre-bariatric surgery decision and work-up Nutrient screening Endocrine evaluation B12 Vitamin D ferritin A1c TSH, T3 with suspected or diagnosed pre-diabetes or diabetes Pre-op if not done in last 30 days N.A Pre-op if not done in last 30 days Can be repeated if abnormal previously and the condition is under treatment Doc Ctrl No.: TEMP/MSD-008 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 7 of 7