Clinical Policy Guideline

Transcription

1 Clinical Policy Guideline Policy Title: Obesity Medical/Surgical Management Effective Date: 07/13/2004 Date Reviewed: 06/18/2011, 12/15/2011, 02/22/2012, 06/26/2012, 07/16/2012, 01/23/2013, 11/26/2014, 05/27/2015, 07/29/2015 I. DEFINITION Body mass index (BMI) has become the medical standard used to define obesity. BMI is an estimate used to determine if a person may be at health risk due to excessive weight BMI is defined as weight (W-in kilograms) divided by height (h-meters) squared [BMI = (W/H)²]. These guidelines are based on the National Institute of Health (NIH) guidelines, which were derived from information obtained from the evidence-based clinical information and published scientific literature in the cooperative effort between the National Lung and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Disease to prepare general national guidelines for the identification, evaluation and treatment of obesity. A healthy weight is defined as a BMI from 18.5 to 24.9, the range of lowest statistical health risk. A BMI greater than 29.9 indicates obesity and potentially significant health risks. Adult s 18 years of age are assigned a weight classification based upon their BMI: BMI (Kg/m²) Underweight < 18.5 Normal Overweight Obese Class I Obese Class II Morbid Obesity Class III > 40.0 Page 1 of 8

2 Co-morbidities are diseases that in the presence of a primary disease such as obesity can increase the negative impact on a patient s health. Members are considered to be at high risk if they have one of the following co-morbid diseases: Severe cardio-pulmonary conditions Type 2 diabetes Sleep Apnea In addition, if a member has three or more of the following poorly controlled co-morbid conditions, they are also considered to be at high risk: Hypertension High LDL Cholesterol Low HDL cholesterol Impaired fasting glucose Smoking Family history of early cardiovascular disease > 45 years of age for men or > 55 years of age for women Osteoarthritis (severe, lower extremity) II. POLICY/CRITERIA Prior to receiving the benefit coverage provided below, many members can achieve an improved weight status through regular monitoring and counseling with their primary care physician. Sometimes this may include utilizing the behavioral health benefits to address behaviors or factors associated with elevated weight or obesity. The behavioral health benefit is recommended to be used for evaluation and possible treatment when medically indicated for counseling of depression, low self-esteem, binge eating, and other related psychological disorders. The primary care physician (PCP) is encouraged to consider this option according to the patient s medical needs. However, some members may require more intervention to assist with weight loss. Benefit coverage for the medical management of obesity is structured in three levels. All levels of weight management in this guideline must have the member s assessment for weight management intervention incorporate a thorough evaluation by Plan-approved providers such as the primary care physician, dietitians and psychologists. It must address the patient s medical history, nutritional history, and psychosocial evaluation, readiness to change, and the current exercise and activity level. Page 2 of 8

3 Documentation supporting medical necessity must be demonstrated in the member s medical record. Documentation must be legible and contain relevant history and physical findings and support the criteria listed in this policy. In addition, members must meet the following criteria for all levels of obesity medical/ surgical management: 1. The member must have a strong desire, willingness and cognitive ability to make changes in diet and activity level, which must be documented by the member s physician. 2. The member must have undergone evaluation to rule out other treatable causes of obesity. 3. The member must not have any contraindication for the level of care requested. Level 1: Education and Counseling Nutritional counseling by a registered dietitian for obesity/weight loss is a covered benefit. (See References:..\..\Ref & Ctrl\Guidelines\NUTRITIONAL COUNSELING.doc). Intensive Behavioral Counseling in the primary care setting, (as described in CMS Decision Memo November 2011) is also a covered benefit, unless otherwise excluded by the member s benefit plan. Under certain circumstances, with the Plan or Corporate Medical Director s authorization, there may be medically justifiable reasons for consideration of a medically accepted, physician-supervised, weight loss and/or exercise program. Level 2: Pharmacotherapy Medications for weight loss are a covered benefit when criteria for prior authorization are met, unless otherwise limited by a member s benefit plan. Criteria for use of weight loss medications are established by the HealthPlus Pharmacy and Therapeutics Committee. Renewal of medications may be authorized for up to one year of total coverage. Level 3: Surgery The use of surgery may be necessary in cases of extreme morbid obesity when the use of more conservative methods of weight loss have failed, and the patient is at high risk for obesity-associated complications. The requirement for coverage by HealthPlus is that the surgery must be performed by a surgeon who is part of a comprehensive medically managed program that will provide guidance and counseling concerning the necessary dietary regimen, appropriate physical activity, and behavioral health support prior to and after the bariatric procedure. Page 3 of 8

4 Bariatric surgery may be covered when all of the following criteria are met and documented by the physician: A. Member must have a BMI of > 35 and be considered high risk as defined at the end of Sec. II. or BMI > 40 with no co-morbidities, and documented by a physician. B. A referral from the PCP is required for all HMO members. C. The patient is an adult > 18 years of age. D. A thorough Behavioral Health assessment and evaluation, preferably including the Minnesota Multiphasic Personality Inventory (MMPI) II test, must be performed by a HealthPlus contracted provider order to establish the member s emotional stability and ability to comply with postsurgical limitations. A HealthPlus Plan Medical Director may require an assessment independent of the surgical program. E. Documentation of counseling of the patient to ensure understanding of and commitment to the life-long medical surveillance and dietary limitations necessary after the procedure, that there is no proven benefit from the procedure of a reduction in mortality rate, and that there is a possible risk of increased mortality rate from the procedure. F. The medical records must document that the member failed a medically supervised weight loss program within two years of the surgical intervention and it addressed dietary, exercise, and behavioral components. G. The clinical documentation must show compliance with a prescribed weight loss regimen, unless contraindicated, for a minimum of six continuous months and within one year of the request of surgical intervention. H. The bariatric surgeries covered are limited to only gastric bypass (Roux-en Y procedure), bileopancreatic diversion, vertical banded gastroplasty, laparoscopic adjustable silicone banding and sleeve gastrectomy unless otherwise specified by the member s benefit plan. J. It is recommended, but not required, surgical procedure to be performed the following accredited facilities: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) approved facility. K. Coverage is limited to one bariatric surgery per lifetime regardless of insurance carrier at the time of surgery, unless medically/clinically necessary to correct or reverse complications from a previous bariatric procedure. III. PRIOR AUTHORIZATION REQUIREMENTS Prior authorization is required by Plan Medical Director. IV. CODING/MODIFIERS/LOCATION OF SERVICE Page 4 of 8

5 90791 Psychiatric diagnostic evaluation Psychological testing (includes psycho-diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Roschach, WAIS), per hour of the psychologist s or physician s time, both face to face time administering tests to the patient and time interpreting test results and preparing the report Psychological testing (includes psycho-diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face to face Psychological testing (includes psycho-diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI) administered by a computer, with qualified health care professional interpretation and report Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) Laparoscopy with gastric bypass and small intestine reconstruction to limit absorption. (Do not report in conjunction with or 43847) Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable restrictive procedure placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only Laparoscopy, surgical gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie. Sleeve gastrectomy) Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical banded gastroplasty. (Not Covered by Medicare) Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than verticalbanded gastroplasty Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatric diversion with duodenal switch) Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (less than 100 cm) Roux-en-Y gastroenterostomy Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption Page 5 of 8

6 43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) Gastric restrictive procedure, open, revision of subcutaneous port component only Gastric restrictive procedure, open; removal of subcutaneous port component only Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only Unlisted procedure, stomach (Covered with prior authorization and documentation) G0447 Face to face behavioral counseling for obesity; 15 minutes ICD-9 Covered Diagnoses: Obesity, Unspecified Morbid Obesity V85.35 Body Mass Index adult V85.36 Body Mass Index adult V85.37 Body Mass Index adult V85.38 Body Mass Index adult V85.39 Body Mass Index adult V85.4 Body Mass Index 40 and over, adult Attached is a document of ICD9 codes mapped to ICD10 codes for Obesity Medical Surgical Management Requirements G:\Ref & Ctrl\ICD10 Mapping\Copy of Obesity Medical-Surgical ICD10 Mapping.pdf Covered Location of Service: 11- Office 21- Inpatient 22- Outpatient V. PRODUCT LINE COVERAGE Please reference contract benefit rider, benefit description, Master Plan Document, Evidence of Coverage (EoC) and Certificate of Coverage (CoC) for applicable limits and copayments, including other exceptions and/or exclusions for specific coverage. If there is a conflict between this medical policy and the individual or group insurance policy document, the terms of the individual or group insurance policy will govern, unless specifically noted. Page 6 of 8

7 HMO: This policy applies to insured HMO plans; refer to the CoC or benefit rider for exceptions or exclusions. PPO: This policy applies to PPO plans; refer to the CoC for any exceptions or exclusions. SELF-FUNDED OPTIONS: This policy applies to self-funded option plans; refer to the Master Plan Document for any exceptions or exclusions. MEDICARE ADVANTAGE: This policy applies to insured Medicare Advantage plans; refer to the EoC for any exceptions or exclusions. MEDICAID: This policy applies to Medicaid plans; refer to the subscriber contract for exceptions or exclusions. HEALTHY MICHIGAN PLAN: This policy applies to Healthy Michigan Plan; refer to the subscriber contract for any exceptions or exclusions. MICHILD: This policy applies to insured MICHILD plans; refer to the subscriber contract for any exceptions or exclusions. COUNTY HEALTH PLANS: This policy applies to County Health Plans; refer to the benefit description for any exceptions or exclusions. VI. REFERENCES Intensive Behavorial Therapy for Obesity. (March 7, 2012). Centers for Medicare and Medicaid Services. MLM Matters. Retrieved from: Network-MLN/MLNMattersArticles/downloads/MM7641.pdf Medicare Approved Facilities; Bariatric Surgery; Information/MedicareApprovedFacilitie/Bariatric-Surgery.html Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP); AMA CPT Copyright Statement: All Current Procedure Terminology (CPT) codes, descriptions, and other data are copyrighted by the American Medical Association. This policy is for informational use only; therefore it is not an authorization of services. HealthPlus of Michigan s clinical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and Page 7 of 8

8 technology are constantly changing, HealthPlus of Michigan reserves the right to review and update its clinical policies at its discretion. HealthPlus of Michigan s clinical policies are intended to serve as a resource to the plan; however they are not intended to limit the plan s interpretation of benefit language. HealthPlus of Michigan does not provide health care services and cannot guarantee results or outcomes. Treating providers are solely responsible for rendering medical advice and treatment to members. Page 8 of 8