INSURANCE AUTHORIZATION REQUIREMENTS

Transcription

1 PHOENIX BARIATRIC CENTER, PLC 3805 E Bell Rd, Suite 5300 Phoenix, AZ Ph Fax Kurt W. Sprunger, MD, FACS INSURANCE AUTHORIZATION REQUIREMENTS ALL PATIENTS Age 18 or older Phoenix Bariatric Center Seminar Attendance Certificate PCP Bariatric Referral Letter (Letter of Medical Necessity) Initial Consultation with Bariatric Surgeon INSURANCE COMPANY REQUIREMENT SUMMARIES ABRAZO ADVANTAGE (MEDICARE) Documentation of Severe/ Morbid Obesity for at least the past 3 (2-3 office notes per Documentation of Medically Supervised Weight Loss by a physician (may be bariatric surgeon) for 6 consecutive months within the past 2 Failed 3 month trial of at least one obesity drug AETNA BMI 40 or greater, or BMI with specific comorbidities (See AETNA specific page) Documentation of Severe/ Morbid Obesity for at least the past 2 Completion of 6 month Physician-supervised nutrition and exercise program or 3 month Multidisciplinary surgical preparatory regimen (See AETNA specific page) Psychology clearance ONLY for patients who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, depression) or who are currently under the care of a psychologist or psychiatrist or who are on psychotropic/ antidepressant medications ANTHEM BCBS (Includes: Blue Cross KY, WI, OH, CA, GA, MO, NY Empire) BMI 40 or greater, or BMI with a comorbidity (See ANTHEM BCBS specific page)

2 Specific Medically Supervised Weight Loss requirement not stipulated COE required APIPA (ARIZONA PHYSICIANS IPA) / UNITED HEALTHCARE COMMUNITY PLAN BMI 40 or greater, or BMI with a comorbidities Documentation of Medically Supervised Weight Loss 6 consecutive within the past two ARIZONA FOUNDATION for MEDICAL CARE (AFMC) BMI 40 or greater with life-threatening comorbid condition Documentation of Severe Obesity for 5 (must include documented weight history, 2-3 office notes per BLUE CROSS BLUE SHIELD of ARIZONA (BCBS AZ) BMI 40 or greater, or BMI with comorbidities (See BCBS AZ specific page) Documentation of Severe/ Morbid Obesity for past 5 Documentation of Medically Supervised Weight Loss at least 8 weeks within past 12 months (See BCBS AZ specific page) Requires Blue Distinction Center CIGNA BMI 40 or greater, or BMI with at least one comorbidity Documentation of Medically Supervised Weight Loss for 3 consecutive months by PCP or Dietitian GREAT WEST HEALTHCARE (Requirements are the same as CIGNA) BMI 40 or greater, or BMI with at least one comorbidity

3 Documentation of Medically Supervised Weight Loss for 3 consecutive months by PCP or Dietitian HEALTH CHOICE Documentation of Medically Supervised Weight Loss for 12 consecutive months within last 2, including food diary - total daily calorie intake, total daily fat grams, food groups used, conditions where overeating occurs; and physical activity log - frequency, intensity and duration of exercise Documentation from PCP of smoking cessation for 6 months HEALTH NET of ARIZONA HEALTH NET of ARIZONA (MEDICARE) HUMANA Documentation of Severe Obesity for 2 (documented weight history, 2-3 office notes per HUMANA (MEDICARE) Documentation of Severe Obesity for 2 (documented weight history, 2-3 office notes per

4 MARICOPA INTEGRATED HEALTH PLAN MEDICARE Documentation that patient has been previously unsuccessful with medical treatment for obesity. Cardiac and Pulmonary Clearances COE required MERCY CARE Documentation of Severe Obesity for 2 (documented weight history, 2-3 office notes per preferred within last 90 days Documentation of Medically Supervised Weight Loss by PCP for 6 consecutive months within the past year (including daily food log or food journal for 6 months) Normal TSH within last 6 months Cardiac and Pulmonary must be approved by Mercy Care Plan; preferred within last 90 days MERITAIN HEALTH BMI 40 or greater, or BMI with comorbidities Documentation of Severe/ Morbid Obesity for past 5 (perhaps should be stated in LOMN and H&P) Documentation of Medically Supervised Weight Loss for 6 consecutive months or two periods of 3 consecutive months each within the past 2 Cardiac clearance Other Clearances are discretionary Covered procedures: Gastric Bypass, Adjustable Gastric Band

5 PACIFICARE of ARIZONA Documentation of Severe/ Morbid Obesity for past one year (documented weight history; 2-3 office notes per PHOENIX HEALTH PLAN (PHP) Documentation of Severe/ Morbid Obesity for at least the past 3 (2-3 office notes per Documentation of Medically Supervised Weight Loss by a physician (may be bariatric surgeon) for 6 consecutive months within the past 2 Failed 3 month trial of at least one obesity drug SECURE HORIZONS / PACIFICARE of ARIZONA (MEDICARE) Documentation of Severe/ Morbid Obesity for past one year (documented weight history; 2-3 office notes per TRICARE BMI 40 or greater, or BMI with one comorbidity not stipulated not stipulated Documentation failure of non-surgical treatments for obesity (See TRICARE specific page) Covered procedures: Gastric Bypass, Adjustable Gastric Band; NOT Sleeve Gastrectomy Required to have surgery at an approved VA facility or other network providers in the TRICARE region where you are enrolled. UNITED HEALTHCARE BMI 40 or greater, or BMI with one or more comorbidities (See UHC specific page) Documentation of Medically Supervised Weight Loss for 6 months.