1. Documentation of a continuous six month period or longer of all medical treatment modality
2. Documentation of the recipient’s weight for three separate years.
3. The recipient’s present weight, height, skeletal frame, body mass index and gender.
4. Medical history of all of the recipient’s diagnoses such as hypertension, heart problems, pulmonary problems, arthritis, joint pains, back problems, etc.
5. A complete listing of all the recipient’s medications.
6. Blood pressures, fasting blood sugar levels, pulmonary study results, orthopedic x-ray reports, etc.
7. Documentation that all correctable causes of obesity have been ruled out with test results of laboratory tests performed, such as thyroid panel, etc.
8. Documentation of a psychological evaluation assessing the recipient’s suitability for surgery and his/her ability to comply with lifelong dietary changes and medical follow up. Components of such an assessment should include: levels of depression, eating behaviors, stress management, cognitive abilities, social functioning, self-esteem, personality factors or other mental health diagnoses that may affect treatment, readiness and ability to adhere to required lifestyle modifications and follow up/social support.
9. Documentation of a fully developed, 5-year psychosocial, nutritional, and activity-based follow-up plan.
10. Certification that the recipient has been informed about all surgery risks, surgery sequelae, the need for extensive follow-up care, expectancy of weight loss and a signed statement that the recipient has been informed of the risks and results and still desires a surgical procedure.
11. Description of the type of gastro-bariatric surgery planned and CPT code that describes the surgery planned.
An increasing number of requests have been submitted without the required documentation of a
Prior approval requests without all of the required documentation listed above will be returned to the provider.
Please refer to DMA’s web site at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm for a copy of clinical coverage policy 1A-15. As well, my therapist has connected me with a surgeon (can't find his name this minute) and they informed me that the hospital in Franklinton, NC is undergoing the process to become a COE hospital ...... Yea me!! Since I live in Wake Forest and that would be soooooo Convenient for me.
I detemine Medicaid eligibility in NC. I have had numerous clients who had the surgery and Duke excepted the Medicaid. Medicaid does require a 6 month weight loss program supervised by your doctor.
hope this helps.....and best wishes.
Jonelle.....surgery date 08/11/2008