Medical Assistance Bariatric Serivces
Here is some information on Bariatric Services for Minnesota Medical Assistance. This is right from the provider manual that the providers use for their criteria to pre authorizes the service.
Authorization Standards for Adult Bariatric Surgery
The following criteria apply only to MHCP enrollees ages 18 and older. See the separate criteria for the adolescent population.
All four of the criteria listed below must be met in order to authorize bariatric surgery. Patients not meeting the criteria, who have one or more immediate, life-threatening comorbidities, will be considered for approval on a case-by-case basis:
? The recipient is clinically obese with one of the following:
? BMI of 40 or higher
? BMI of 35-40 with one or more of the following comorbid conditions:
? Severe cardiac disease (coronary artery disease, pulmonary hypertension, congestive heart failure, or cardiomyopathy)
? Type 2 diabetes
? Obstructive sleep apnea and other respiratory disease (chronic asthma, obesity hypoventilation syndrome, or Pickwickian syndrome)
? Pseudo-tumor cerebri
? Gastroesophageal reflux disease
? Hypertension
? Hyperlipidemia
? Severe joint or disc disease that interferes with daily functioning
The BMI level qualifying the patient for surgery (> 40 or > 35 with one of the above comorbidities) must be of at least two years duration.
A patient's required attempt(s) to lose weight may cause their BMI to fluctuate around the discrete required levels during the two-year period. The two-year period will not necessarily start over, or be prolonged, under this scenario, but will be decided on a case-by-case basis.
? The recipient has made at least one serious medically supervised attempt to lose weight in the past, under the supervision of a physician, physician's assistant, nurse practitioner, or registered dietician. The medically supervised weight loss attempt(s) must have been at least six months in duration
? Medical and psychiatric contraindications to the surgical procedure have been ruled out through:
? A complete history and physical conducted by the requesting surgeon
? A psychiatric/psychological assessment, conducted by a licensed mental health professional, no more than three months prior to the requested authorization. The assessment must address both potential psychiatric contraindications and patient ability to comply with the postoperative care plan
? The recipient:
? Is motivated and committed to losing weight
? Has realistic expectations of the surgical outcome
? Postoperatively is willing to make permanent lifestyle changes in the areas of:
? Eating behaviors
? Other behaviors and
? Exercise therapy
? Willing to participate in the long-term postoperative care plan offered by the surgery program, consisting of:
? Diet therapy
? Behavior modification
? Activity/exercise components
Required Written Documentation
? Recipient's height, weight, and BMI with duration
? All co-morbid conditions listed and described
? A detailed statement of the recipient's past medically supervised weight loss attempt(s) lasting six months or more (including the duration of each attempt)
? The recipient's current eating habits
? A list of applicable medical and/or psychiatric contraindications
? A copy of the current psychiatric/psychological assessment as described above
? A statement detailing the recipient's:
? commitment to lose weight
? expectations of the surgical outcome
? willingness to make permanent life-style changes
? A description of the post-surgical follow-up program (submitted on a one-time basis). This description will be kept on file with the medical reviewer for each surgeon
Authorization Standards for Adolescents Bariatric Surgery
The following criteria apply only to carefully selected MHCP enrollees below the age of 18. The procedure will be considered for authorization on a case-by-case basis. The following criteria represent the consensus of available expert opinion.
All of the criteria listed below must be met in order for bariatric surgery to be authorized. Patients not meeting the criteria, who have one or more immediate life-threatening comorbidities, will be considered for approval on a case-by-case basis.
? The recipient is clinically obese with:
? BMI of 40 or higher with one or more of the following comorbid conditions:
? Obstructive Sleep Apnea
? Pseudotumor Cerebri
? Severe/Complicated Hypertension
? Type 2 Diabetes, or
? BMI of 50 or higher with one or more of the following comorbid conditions:
? Arthropathies in Weight-Bearing Joints
? Dyslipidemias
? Gastroesophageal Reflux Disease
? Hypertension
? Intertriginous Soft-Tissue Infections
? Nonalcoholic Steatohepatitis
? Obesity-Related Psychosocial Distress
? Significant Impairment in Activities of Daily Living (ADL)
? Stress Urinary Incontinence
? Venous Stasis Disease
? The recipient has made at least one serious, medically supervised attempt to lose weight in the past, under the supervision of a physician, physician's assistant, nurse practitioner, or registered dietician. The medically supervised weight loss attempt(s) as defined above must have been at least six months in duration
? Medical and psychiatric contraindications to the surgical procedure were ruled out (and referrals made as necessary) through both:
? A complete history and physical, including the exclusion or diagnosis of genetic or syndromic obesity, such as Prader-Willi Syndrome
? A psychiatric/psychological assessment, conducted by a licensed mental health professional, no more than three months prior to the requesting authorization. The evaluation should address these issues:
? Ability to provide informed assent without coercion
? Family and social support
? Patient ability to comply with the postoperative care plan and
? Potential psychiatric contraindications
? The recipient:
? Has realistic expectations of the surgical outcome
? Is motivated and committed to losing weight
? Postoperatively is willing to make permanent lifestyle changes in the areas of:
? Eating behaviors
? Exercise therapy with their family's support
? Other behaviors
? Willing to participate in the adolescent-specific, long-term postoperative care plan offered by the surgery program. The care plan consists of:
? Activity/exercise components
? Behavior modification
? Diet therapy
? The recipient has attained physiologic maturity as measured by both:
? The attainment of Tanner stage IV development
? The attainment of 95% of adult height based on estimates from bone age
Note: Female recipients cannot be pregnant or breast-feeding and they do not plan to become pregnant within 2 years following surgery.
Required Written Documentation
? Recipient's height, weight, and BMI
? All co-morbid conditions listed and described
? A detailed statement of the recipient's past medically supervised weight loss attempt(s) lasting six months or more (including the duration of each attempt)
? The recipient's current eating habits
? A list of applicable medical and/or psychiatric contraindications
? A copy of the current psychiatric/psychological assessment as described above
? A statement detailing the recipient's:
? commitment to lose weight
? expectations of the surgical outcome
? willingness to make permanent life-style changes
? A statement detailing at least one custodial parent or guardian's:
? commitment to support and facilitate the recipient's loss of weight
? expectations of the surgical outcome
? willingness to support and facilitate permanent life-style changes
? A description of the post-surgical follow-up program, which must be part of a multi-disciplinary pediatric weight management program. This description will be submitted (on a one-time basis) and kept on file with the medical reviewer for each surgeon and program.
? A statement verifying the attainment of physiologic maturity as defined above
? Verification counseling was provided to female adolescents regarding potential birth defects from nutritional deficiencies if they become pregnant during the weight stabilization period following surgery.
Required Documentation for Revision of Bariatric Surgery
? Date and type of the initial surgery
? Weight loss history after the surgery
? Present height and weight
? Dietary assessment regarding current eating habits
? X-ray or endoscopic report that demonstrates the staple line has failed or the pouch has enlarged
? Psychiatric contraindications to the surgery have been ruled out. If the patient is currently receiving psychiatric treatment, a current diagnostic assessment must be submitted
Authorization Standards for Adult Bariatric Surgery
The following criteria apply only to MHCP enrollees ages 18 and older. See the separate criteria for the adolescent population.
All four of the criteria listed below must be met in order to authorize bariatric surgery. Patients not meeting the criteria, who have one or more immediate, life-threatening comorbidities, will be considered for approval on a case-by-case basis:
? The recipient is clinically obese with one of the following:
? BMI of 40 or higher
? BMI of 35-40 with one or more of the following comorbid conditions:
? Severe cardiac disease (coronary artery disease, pulmonary hypertension, congestive heart failure, or cardiomyopathy)
? Type 2 diabetes
? Obstructive sleep apnea and other respiratory disease (chronic asthma, obesity hypoventilation syndrome, or Pickwickian syndrome)
? Pseudo-tumor cerebri
? Gastroesophageal reflux disease
? Hypertension
? Hyperlipidemia
? Severe joint or disc disease that interferes with daily functioning
The BMI level qualifying the patient for surgery (> 40 or > 35 with one of the above comorbidities) must be of at least two years duration.
A patient's required attempt(s) to lose weight may cause their BMI to fluctuate around the discrete required levels during the two-year period. The two-year period will not necessarily start over, or be prolonged, under this scenario, but will be decided on a case-by-case basis.
? The recipient has made at least one serious medically supervised attempt to lose weight in the past, under the supervision of a physician, physician's assistant, nurse practitioner, or registered dietician. The medically supervised weight loss attempt(s) must have been at least six months in duration
? Medical and psychiatric contraindications to the surgical procedure have been ruled out through:
? A complete history and physical conducted by the requesting surgeon
? A psychiatric/psychological assessment, conducted by a licensed mental health professional, no more than three months prior to the requested authorization. The assessment must address both potential psychiatric contraindications and patient ability to comply with the postoperative care plan
? The recipient:
? Is motivated and committed to losing weight
? Has realistic expectations of the surgical outcome
? Postoperatively is willing to make permanent lifestyle changes in the areas of:
? Eating behaviors
? Other behaviors and
? Exercise therapy
? Willing to participate in the long-term postoperative care plan offered by the surgery program, consisting of:
? Diet therapy
? Behavior modification
? Activity/exercise components
Required Written Documentation
? Recipient's height, weight, and BMI with duration
? All co-morbid conditions listed and described
? A detailed statement of the recipient's past medically supervised weight loss attempt(s) lasting six months or more (including the duration of each attempt)
? The recipient's current eating habits
? A list of applicable medical and/or psychiatric contraindications
? A copy of the current psychiatric/psychological assessment as described above
? A statement detailing the recipient's:
? commitment to lose weight
? expectations of the surgical outcome
? willingness to make permanent life-style changes
? A description of the post-surgical follow-up program (submitted on a one-time basis). This description will be kept on file with the medical reviewer for each surgeon
Authorization Standards for Adolescents Bariatric Surgery
The following criteria apply only to carefully selected MHCP enrollees below the age of 18. The procedure will be considered for authorization on a case-by-case basis. The following criteria represent the consensus of available expert opinion.
All of the criteria listed below must be met in order for bariatric surgery to be authorized. Patients not meeting the criteria, who have one or more immediate life-threatening comorbidities, will be considered for approval on a case-by-case basis.
? The recipient is clinically obese with:
? BMI of 40 or higher with one or more of the following comorbid conditions:
? Obstructive Sleep Apnea
? Pseudotumor Cerebri
? Severe/Complicated Hypertension
? Type 2 Diabetes, or
? BMI of 50 or higher with one or more of the following comorbid conditions:
? Arthropathies in Weight-Bearing Joints
? Dyslipidemias
? Gastroesophageal Reflux Disease
? Hypertension
? Intertriginous Soft-Tissue Infections
? Nonalcoholic Steatohepatitis
? Obesity-Related Psychosocial Distress
? Significant Impairment in Activities of Daily Living (ADL)
? Stress Urinary Incontinence
? Venous Stasis Disease
? The recipient has made at least one serious, medically supervised attempt to lose weight in the past, under the supervision of a physician, physician's assistant, nurse practitioner, or registered dietician. The medically supervised weight loss attempt(s) as defined above must have been at least six months in duration
? Medical and psychiatric contraindications to the surgical procedure were ruled out (and referrals made as necessary) through both:
? A complete history and physical, including the exclusion or diagnosis of genetic or syndromic obesity, such as Prader-Willi Syndrome
? A psychiatric/psychological assessment, conducted by a licensed mental health professional, no more than three months prior to the requesting authorization. The evaluation should address these issues:
? Ability to provide informed assent without coercion
? Family and social support
? Patient ability to comply with the postoperative care plan and
? Potential psychiatric contraindications
? The recipient:
? Has realistic expectations of the surgical outcome
? Is motivated and committed to losing weight
? Postoperatively is willing to make permanent lifestyle changes in the areas of:
? Eating behaviors
? Exercise therapy with their family's support
? Other behaviors
? Willing to participate in the adolescent-specific, long-term postoperative care plan offered by the surgery program. The care plan consists of:
? Activity/exercise components
? Behavior modification
? Diet therapy
? The recipient has attained physiologic maturity as measured by both:
? The attainment of Tanner stage IV development
? The attainment of 95% of adult height based on estimates from bone age
Note: Female recipients cannot be pregnant or breast-feeding and they do not plan to become pregnant within 2 years following surgery.
Required Written Documentation
? Recipient's height, weight, and BMI
? All co-morbid conditions listed and described
? A detailed statement of the recipient's past medically supervised weight loss attempt(s) lasting six months or more (including the duration of each attempt)
? The recipient's current eating habits
? A list of applicable medical and/or psychiatric contraindications
? A copy of the current psychiatric/psychological assessment as described above
? A statement detailing the recipient's:
? commitment to lose weight
? expectations of the surgical outcome
? willingness to make permanent life-style changes
? A statement detailing at least one custodial parent or guardian's:
? commitment to support and facilitate the recipient's loss of weight
? expectations of the surgical outcome
? willingness to support and facilitate permanent life-style changes
? A description of the post-surgical follow-up program, which must be part of a multi-disciplinary pediatric weight management program. This description will be submitted (on a one-time basis) and kept on file with the medical reviewer for each surgeon and program.
? A statement verifying the attainment of physiologic maturity as defined above
? Verification counseling was provided to female adolescents regarding potential birth defects from nutritional deficiencies if they become pregnant during the weight stabilization period following surgery.
Required Documentation for Revision of Bariatric Surgery
? Date and type of the initial surgery
? Weight loss history after the surgery
? Present height and weight
? Dietary assessment regarding current eating habits
? X-ray or endoscopic report that demonstrates the staple line has failed or the pouch has enlarged
? Psychiatric contraindications to the surgery have been ruled out. If the patient is currently receiving psychiatric treatment, a current diagnostic assessment must be submitted
Authorization Standards for Adult Bariatric Surgery
The following criteria apply only to MHCP enrollees ages 18 and older. See the separate criteria for the adolescent population.
All four of the criteria listed below must be met in order to authorize bariatric surgery. Patients not meeting the criteria, who have one or more immediate, life-threatening comorbidities, will be considered for approval on a case-by-case basis:
? The recipient is clinically obese with one of the following:
? BMI of 40 or higher
? BMI of 35-40 with one or more of the following comorbid conditions:
? Severe cardiac disease (coronary artery disease, pulmonary hypertension, congestive heart failure, or cardiomyopathy)
? Type 2 diabetes
? Obstructive sleep apnea and other respiratory disease (chronic asthma, obesity hypoventilation syndrome, or Pickwickian syndrome)
? Pseudo-tumor cerebri
? Gastroesophageal reflux disease
? Hypertension
? Hyperlipidemia
? Severe joint or disc disease that interferes with daily functioning
The BMI level qualifying the patient for surgery (> 40 or > 35 with one of the above comorbidities) must be of at least two years duration.
A patient's required attempt(s) to lose weight may cause their BMI to fluctuate around the discrete required levels during the two-year period. The two-year period will not necessarily start over, or be prolonged, under this scenario, but will be decided on a case-by-case basis.
? The recipient has made at least one serious medically supervised attempt to lose weight in the past, under the supervision of a physician, physician's assistant, nurse practitioner, or registered dietician. The medically supervised weight loss attempt(s) must have been at least six months in duration
? Medical and psychiatric contraindications to the surgical procedure have been ruled out through:
? A complete history and physical conducted by the requesting surgeon
? A psychiatric/psychological assessment, conducted by a licensed mental health professional, no more than three months prior to the requested authorization. The assessment must address both potential psychiatric contraindications and patient ability to comply with the postoperative care plan
? The recipient:
? Is motivated and committed to losing weight
? Has realistic expectations of the surgical outcome
? Postoperatively is willing to make permanent lifestyle changes in the areas of:
? Eating behaviors
? Other behaviors and
? Exercise therapy
? Willing to participate in the long-term postoperative care plan offered by the surgery program, consisting of:
? Diet therapy
? Behavior modification
? Activity/exercise components
Required Written Documentation
? Recipient's height, weight, and BMI with duration
? All co-morbid conditions listed and described
? A detailed statement of the recipient's past medically supervised weight loss attempt(s) lasting six months or more (including the duration of each attempt)
? The recipient's current eating habits
? A list of applicable medical and/or psychiatric contraindications
? A copy of the current psychiatric/psychological assessment as described above
? A statement detailing the recipient's:
? commitment to lose weight
? expectations of the surgical outcome
? willingness to make permanent life-style changes
? A description of the post-surgical follow-up program (submitted on a one-time basis). This description will be kept on file with the medical reviewer for each surgeon
Authorization Standards for Adolescents Bariatric Surgery
The following criteria apply only to carefully selected MHCP enrollees below the age of 18. The procedure will be considered for authorization on a case-by-case basis. The following criteria represent the consensus of available expert opinion.
All of the criteria listed below must be met in order for bariatric surgery to be authorized. Patients not meeting the criteria, who have one or more immediate life-threatening comorbidities, will be considered for approval on a case-by-case basis.
? The recipient is clinically obese with:
? BMI of 40 or higher with one or more of the following comorbid conditions:
? Obstructive Sleep Apnea
? Pseudotumor Cerebri
? Severe/Complicated Hypertension
? Type 2 Diabetes, or
? BMI of 50 or higher with one or more of the following comorbid conditions:
? Arthropathies in Weight-Bearing Joints
? Dyslipidemias
? Gastroesophageal Reflux Disease
? Hypertension
? Intertriginous Soft-Tissue Infections
? Nonalcoholic Steatohepatitis
? Obesity-Related Psychosocial Distress
? Significant Impairment in Activities of Daily Living (ADL)
? Stress Urinary Incontinence
? Venous Stasis Disease
? The recipient has made at least one serious, medically supervised attempt to lose weight in the past, under the supervision of a physician, physician's assistant, nurse practitioner, or registered dietician. The medically supervised weight loss attempt(s) as defined above must have been at least six months in duration
? Medical and psychiatric contraindications to the surgical procedure were ruled out (and referrals made as necessary) through both:
? A complete history and physical, including the exclusion or diagnosis of genetic or syndromic obesity, such as Prader-Willi Syndrome
? A psychiatric/psychological assessment, conducted by a licensed mental health professional, no more than three months prior to the requesting authorization. The evaluation should address these issues:
? Ability to provide informed assent without coercion
? Family and social support
? Patient ability to comply with the postoperative care plan and
? Potential psychiatric contraindications
? The recipient:
? Has realistic expectations of the surgical outcome
? Is motivated and committed to losing weight
? Postoperatively is willing to make permanent lifestyle changes in the areas of:
? Eating behaviors
? Exercise therapy with their family's support
? Other behaviors
? Willing to participate in the adolescent-specific, long-term postoperative care plan offered by the surgery program. The care plan consists of:
? Activity/exercise components
? Behavior modification
? Diet therapy
? The recipient has attained physiologic maturity as measured by both:
? The attainment of Tanner stage IV development
? The attainment of 95% of adult height based on estimates from bone age
Note: Female recipients cannot be pregnant or breast-feeding and they do not plan to become pregnant within 2 years following surgery.
Required Written Documentation
? Recipient's height, weight, and BMI
? All co-morbid conditions listed and described
? A detailed statement of the recipient's past medically supervised weight loss attempt(s) lasting six months or more (including the duration of each attempt)
? The recipient's current eating habits
? A list of applicable medical and/or psychiatric contraindications
? A copy of the current psychiatric/psychological assessment as described above
? A statement detailing the recipient's:
? commitment to lose weight
? expectations of the surgical outcome
? willingness to make permanent life-style changes
? A statement detailing at least one custodial parent or guardian's:
? commitment to support and facilitate the recipient's loss of weight
? expectations of the surgical outcome
? willingness to support and facilitate permanent life-style changes
? A description of the post-surgical follow-up program, which must be part of a multi-disciplinary pediatric weight management program. This description will be submitted (on a one-time basis) and kept on file with the medical reviewer for each surgeon and program.
? A statement verifying the attainment of physiologic maturity as defined above
? Verification counseling was provided to female adolescents regarding potential birth defects from nutritional deficiencies if they become pregnant during the weight stabilization period following surgery.
Required Documentation for Revision of Bariatric Surgery
? Date and type of the initial surgery
? Weight loss history after the surgery
? Present height and weight
? Dietary assessment regarding current eating habits
? X-ray or endoscopic report that demonstrates the staple line has failed or the pouch has enlarged
? Psychiatric contraindications to the surgery have been ruled out. If the patient is currently receiving psychiatric treatment, a current diagnostic assessment must be submitted
Authorization Standards for Adult Bariatric Surgery
The following criteria apply only to MHCP enrollees ages 18 and older. See the separate criteria for the adolescent population.
All four of the criteria listed below must be met in order to authorize bariatric surgery. Patients not meeting the criteria, who have one or more immediate, life-threatening comorbidities, will be considered for approval on a case-by-case basis:
? The recipient is clinically obese with one of the following:
? BMI of 40 or higher
? BMI of 35-40 with one or more of the following comorbid conditions:
? Severe cardiac disease (coronary artery disease, pulmonary hypertension, congestive heart failure, or cardiomyopathy)
? Type 2 diabetes
? Obstructive sleep apnea and other respiratory disease (chronic asthma, obesity hypoventilation syndrome, or Pickwickian syndrome)
? Pseudo-tumor cerebri
? Gastroesophageal reflux disease
? Hypertension
? Hyperlipidemia
? Severe joint or disc disease that interferes with daily functioning
The BMI level qualifying the patient for surgery (> 40 or > 35 with one of the above comorbidities) must be of at least two years duration.
A patient's required attempt(s) to lose weight may cause their BMI to fluctuate around the discrete required levels during the two-year period. The two-year period will not necessarily start over, or be prolonged, under this scenario, but will be decided on a case-by-case basis.
? The recipient has made at least one serious medically supervised attempt to lose weight in the past, under the supervision of a physician, physician's assistant, nurse practitioner, or registered dietician. The medically supervised weight loss attempt(s) must have been at least six months in duration
? Medical and psychiatric contraindications to the surgical procedure have been ruled out through:
? A complete history and physical conducted by the requesting surgeon
? A psychiatric/psychological assessment, conducted by a licensed mental health professional, no more than three months prior to the requested authorization. The assessment must address both potential psychiatric contraindications and patient ability to comply with the postoperative care plan
? The recipient:
? Is motivated and committed to losing weight
? Has realistic expectations of the surgical outcome
? Postoperatively is willing to make permanent lifestyle changes in the areas of:
? Eating behaviors
? Other behaviors and
? Exercise therapy
? Willing to participate in the long-term postoperative care plan offered by the surgery program, consisting of:
? Diet therapy
? Behavior modification
? Activity/exercise components
Required Written Documentation
? Recipient's height, weight, and BMI with duration
? All co-morbid conditions listed and described
? A detailed statement of the recipient's past medically supervised weight loss attempt(s) lasting six months or more (including the duration of each attempt)
? The recipient's current eating habits
? A list of applicable medical and/or psychiatric contraindications
? A copy of the current psychiatric/psychological assessment as described above
? A statement detailing the recipient's:
? commitment to lose weight
? expectations of the surgical outcome
? willingness to make permanent life-style changes
? A description of the post-surgical follow-up program (submitted on a one-time basis). This description will be kept on file with the medical reviewer for each surgeon
Authorization Standards for Adolescents Bariatric Surgery
The following criteria apply only to carefully selected MHCP enrollees below the age of 18. The procedure will be considered for authorization on a case-by-case basis. The following criteria represent the consensus of available expert opinion.
All of the criteria listed below must be met in order for bariatric surgery to be authorized. Patients not meeting the criteria, who have one or more immediate life-threatening comorbidities, will be considered for approval on a case-by-case basis.
? The recipient is clinically obese with:
? BMI of 40 or higher with one or more of the following comorbid conditions:
? Obstructive Sleep Apnea
? Pseudotumor Cerebri
? Severe/Complicated Hypertension
? Type 2 Diabetes, or
? BMI of 50 or higher with one or more of the following comorbid conditions:
? Arthropathies in Weight-Bearing Joints
? Dyslipidemias
? Gastroesophageal Reflux Disease
? Hypertension
? Intertriginous Soft-Tissue Infections
? Nonalcoholic Steatohepatitis
? Obesity-Related Psychosocial Distress
? Significant Impairment in Activities of Daily Living (ADL)
? Stress Urinary Incontinence
? Venous Stasis Disease
? The recipient has made at least one serious, medically supervised attempt to lose weight in the past, under the supervision of a physician, physician's assistant, nurse practitioner, or registered dietician. The medically supervised weight loss attempt(s) as defined above must have been at least six months in duration
? Medical and psychiatric contraindications to the surgical procedure were ruled out (and referrals made as necessary) through both:
? A complete history and physical, including the exclusion or diagnosis of genetic or syndromic obesity, such as Prader-Willi Syndrome
? A psychiatric/psychological assessment, conducted by a licensed mental health professional, no more than three months prior to the requesting authorization. The evaluation should address these issues:
? Ability to provide informed assent without coercion
? Family and social support
? Patient ability to comply with the postoperative care plan and
? Potential psychiatric contraindications
? The recipient:
? Has realistic expectations of the surgical outcome
? Is motivated and committed to losing weight
? Postoperatively is willing to make permanent lifestyle changes in the areas of:
? Eating behaviors
? Exercise therapy with their family's support
? Other behaviors
? Willing to participate in the adolescent-specific, long-term postoperative care plan offered by the surgery program. The care plan consists of:
? Activity/exercise components
? Behavior modification
? Diet therapy
? The recipient has attained physiologic maturity as measured by both:
? The attainment of Tanner stage IV development
? The attainment of 95% of adult height based on estimates from bone age
Note: Female recipients cannot be pregnant or breast-feeding and they do not plan to become pregnant within 2 years following surgery.
Required Written Documentation
? Recipient's height, weight, and BMI
? All co-morbid conditions listed and described
? A detailed statement of the recipient's past medically supervised weight loss attempt(s) lasting six months or more (including the duration of each attempt)
? The recipient's current eating habits
? A list of applicable medical and/or psychiatric contraindications
? A copy of the current psychiatric/psychological assessment as described above
? A statement detailing the recipient's:
? commitment to lose weight
? expectations of the surgical outcome
? willingness to make permanent life-style changes
? A statement detailing at least one custodial parent or guardian's:
? commitment to support and facilitate the recipient's loss of weight
? expectations of the surgical outcome
? willingness to support and facilitate permanent life-style changes
? A description of the post-surgical follow-up program, which must be part of a multi-disciplinary pediatric weight management program. This description will be submitted (on a one-time basis) and kept on file with the medical reviewer for each surgeon and program.
? A statement verifying the attainment of physiologic maturity as defined above
? Verification counseling was provided to female adolescents regarding potential birth defects from nutritional deficiencies if they become pregnant during the weight stabilization period following surgery.
Required Documentation for Revision of Bariatric Surgery
? Date and type of the initial surgery
? Weight loss history after the surgery
? Present height and weight
? Dietary assessment regarding current eating habits
? X-ray or endoscopic report that demonstrates the staple line has failed or the pouch has enlarged
? Psychiatric contraindications to the surgery have been ruled out. If the patient is currently receiving psychiatric treatment, a current diagnostic assessment must be submitted
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