West Virginia Medicaid Weight Loss Surgery Information

RE:West Virginia Medicaid Program Coverage for Bariatric Surgery ProceduresMANUAL:Hospital and Physician PURPOSE:This Program Instruction transmits West Virginia Medicaid Program policy for coverage andreimbursement of bariatric surgery procedures. BACKGROUND:The West Virginia Medicaid Program discontinued coverage and reimbursement for bariatricsurgery procedures in 1995. Since that time the Medicaid Program has not paid medicalpractitioners or facilities for bariatric surgery procedures. Fairly recent surgical developments havenecessitated re-examination of the non-covered status.POLICY PROVISION: Effective with services rendered on and after January 1, 2004, the West Virginia Medicaid Programwill begin covering bariatric surgery procedures subject to the following conditions:?Medical Necessity Review and Prior AuthorizationThe patient's primary care physician or the bariatric surgeon may initiate the medical necessityreview and prior authorization by submitting a request, along with all the required information,to the West Virginia Medical Institute (WVMI), 3001 Chesterfield Place, Charleston, WestVirginia 25304. The West Virginia Medical Institute (WVMI) will perform medical necessityreview and prior authorization based upon the following criteria:1. A Body Mass Index (BMI) greater than 40 must be present and documented for at least the -------------------------------------------------------------------------------- Page 2 Medicaid Program Instruction MA-03-64Issue Date: November 7, 2003Effective Date: January 1, 2004Page 2past 5 years. Submitted documentation must include height and weight.2. The obesity has incapacitated the patient from normal activity, or rendered the individualdisabled. Physician submitted documentation must substantiate inability to performactivities of daily living without considerable taxing effort, as evidenced by needing to usea walker or wheelchair to leave residence.3. Must be between the ages of 18 and 65. (Special considerations apply if the individual isnot in this age group. If the individual is below the age of 18, submitted documentation mustsubstantiate completion of bone growth.) 4. The patient must have a documented diagnosis of diabetes that is being actively treatedwith oral agents, insulin, or diet modification. The rationale for this criteria is taken from theSwedish Obese Subjects (SOS) study, International Journal of Obesity and RelatedMetabolic Disorders, May, 2001. 5. Patient must have documented failure at two attempts of physician supervised weight loss,attempts each lasting six months or longer. These attempts at weight loss must be withinthe past two years, as documented in the patient medical record, including a description ofwhy the attempt failed. 6. Patient must have had a preoperative psychological and/or psychiatric evaluation within thesix months prior to the surgery. This evaluation must be performed by a psychiatrist orpsychologist, independent of any association with the bariatric surgery facility, and must bespecifically targeted to address issues relative to the proposed surgery. A diagnosis ofactive psychosis; hypochondriasis; obvious inability to comply with a post operativeregimen; bulimia; and active alcoholism or chemical abuse will preclude approval. 7. The patient must demonstrate ability to comply with dietary, behavioral and lifestylechanges necessary to facilitate successful weight loss and maintenance of weight loss.Evidence of adequate family participation to support the patient with the necessary lifelonglifestyle changes is required. 8. Contraindications: Three (3) or more prior abdominal surgeries; history of failed bariatricsurgery;current cancer treatment; Crohn's disease; End Stage Renal Disease (ESRD); priorbowel resection; ulcerative colitis; history of cancer within prior 5 years that is not inremission; prior history of non-compliance with medical or surgical treatments.9. Documentation of a current evaluation for medical clearance of this surgery performed bya cardiologist or pulmonologist, must be submitted to ensure the patient can withstand thestress of the surgery from a medical standpoint.PHYSICIAN CREDENTIALING REQUIREMENTSIn order to be eligible for reimbursement for bariatric surgery procedures, physicians must:?Provide evidence of credentials at an accredited facility to perform gastrointestinal andbiliary surgery. ?Provide documentation that the physician is working within an integrated program for the -------------------------------------------------------------------------------- Page 3 Medicaid Program Instruction MA-03-64Issue Date: November 7, 2003Effective Date: January 1, 2004Page 3care of the morbidly obese that provides ancillary services such as specialized nursing care,dietary instruction, counseling, support groups, exercise training andpsychological/psychiatric assistance as needed. ?Provide assurances that surgeons performing these procedures will follow the guidelinesestablished by the American Society for Bariatric Surgery including:"Credentials to perform open and laporoscopic bariatic surgery"Document at least 25 open and/or laporoscopic bariatic surgeries within the last threeyears PHYSICIAN PROFESSIONAL SERVICESProfessional services which will be required of the physician performing bariatric surgeryinclude the surgical procedure, the 90-day global post-operative follow-up, and a 12 monthassessment period whi*****ludes the following: medical management of the patient's bariatriccare, nutritional and personal lifestyle counseling, and a written report at the end of the 12month period consisting of: an assessment of the patient's weight loss to date, current healthstatus and prognosis, and recommendations for continuing treatment. That 12 monthassessment report must be submitted to the patient's attending or primary care physician, aswell as to the Bureau for Medical Services. While the bariatric surgeon's association with the patient may end following the required 12month follow-up, the patient's continuing care should be managed by the primary care orattending physician throughout the patient's lifetime. REIMBURSEMENT:HospitalParticipating hospitals will be reimbursed for approved admissions through the DRGreimbursement methodology. The hospital must be a facility in which the procedures are performed on a regular basis, andthat has the proper equipment and appropriately trained staff for this specialized surgery, asoutlined by the American College of Surgeons for facilities performing bariatric surgery . WVMIreserves the right to deny the request based on the appropriateness of the facility involved.PhysiciansThephysicianperformingthebariatric surgery procedure will be reimbursed through theexistingRBRVS payment methodology for the surgical procedure. Reimbursement includes a post-operative follow-up for the global period of 90 days. For the remainder of the required 12 monthfollow-up period and assessment, the bariatric surgeon maysubmit claimsusing the appropriateevaluation and management procedure code. After completion of the required 12 monthevaluation period, the patient may be followed-up and medically managed either by the surgeonor primary care physician utilizing appropriate E & M procedure codes. CPT Codes/Covered Procedures -------------------------------------------------------------------------------- Page 4 Medicaid Program Instruction MA-03-64Issue Date: November 7, 2003Effective Date: January 1, 2004Page 443842Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty.43843Gastric restrictive procedure, without gastric bypass, for morbid obesity; other thanvertical-banded gastroplasty.43846Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb(less than 100 cm) Roux-en-Y gastroenterostomy.43847Gastric restrictive procedure, with gastric bypass for morbid obesity; with smallintestine reconstruction to limit absorption.43848Revision of gastric restrictive procedure for morbid obesity (separate procedure).(This is only for correction of serious complications caused by the procedure withinthe first 6 months postoperatively, and is not meant to indicate that a patient canhave a second procedure due to failure to lose weight from a prior procedure.)Only one procedure will be covered per lifetime. Those failing to lose weight from a priorprocedure will not be approved for a second one.Non-Covered ProceduresThe following procedures will not be covered by West Virginia Medicaid Program:?Mini-gastric bypass surgery?Gastric balloon for treatment of obesity?Laparoscopic adjustable gastric bandingINQUIRIES:Inquiries related to the content of this Program Instruction should be directed to ACS, ProviderRelations, Post Office Box 2002, Charleston, West Virginia 25327-2002. The telephone numberis (304) 345-0101, and the toll free number is 1-800-433-3019 (in-state providers only).

Do you have to comply w/ all 7 of their requirements to be approved ? I have started the process of trying to get RNY surgery a few months ago and right now all I have left to do is my psych eval. and it can be submited. If I have to comply w/ all 7 of these then I am looking at a denial. Paula

I have most of those, I can't really see a dr. putting us threw all of these tests and not thinking it will work. Today i see the nutritionest and then i am done. that is if my primary dr. had sent in his report. lol I will check when i at my surgeons office today. if not i will call primary tomorrow and tell him to hurry up. he keeps asking when i am haveing surgery and if i have a date yet. well duh. not if he don't get his part sent in. Good luck with everything.