Effective for dates of service beginning April 15, 2018, Harvard Pilgrim is updating our prior authorization policy for bariatric surgery to require confirmation by a specialist of the presence of certain medical conditions and completion of a medically supervised weight loss and exercise program within a given time frame.
Harvard Pilgrim covers medically necessary bariatric surgery with prior authorization and requires that members receive this procedure at one of the in-network facilities that have been designated as a Weight Loss Surgery Center of Excellence. Information about this program — which is designed to ensure that members receive care that is focused on patient health and safety — can be found in the Weight Loss Surgery Centers of Excellence (COEs) section of our provider website.
Confirmation by specialist
The existing bariatric surgery prior authorization policy requires that medical record documentation confirm either a body mass index (BMI) of 40 or more or a BMI of 35 and the presence of a comorbid condition (from among those listed in the policy). Beginning April 15, 2018, if the patient has one of the following conditions, confirmation must be provided by a physician with the applicable specialty, as indicated below:
- Type II Diabetes – with documentation of diabetes diagnosis consistent with the American Diabetic Association; diagnosis must also be confirmed by an endocrinologist or primary care physician
- Pseudotumor cerebri — diagnosis confirmed and treatment plan supported by neurologist
- Severe arthropathy of spine and/or weight-bearing joints (when obesity prohibits appropriate surgical management of joint dysfunction treatable but for the obesity) — diagnosis must be confirmed by orthopedic surgeon
- Obesity-induced cardiomyopathy — diagnosis must be confirmed by a cardiologist
Obesity-related hypoventilation — diagnosis must be confirmed by a pulmonologist
If your patient has one of these diagnoses, when requesting authorization please submit the patient’s medical record or other documentation that supports that the diagnosis has been made by the appropriate provider. The list above highlights only those conditions requiring confirmation by a specialist and is not inclusive of all comorbid conditions that meet medical criteria; for complete details, please refer to the updated Bariatric Surgeries Medical Review Criteria.
Medically supervised weight loss and exercise program
In addition, under the updated policy, the requesting provider must provide documentation confirming that the patient has completed at least 6 months of a medically supervised weight loss and exercise program in which at least three months are consecutive.
We have updated our Bariatric Surgery Prior Authorization Request Form to reflect these changes. To request authorization, please fax the completed form to 800-232-0816.