Prior Authorization Request for Gastric Restrictive (Bariatric) Surgery Request Form

Medical Policy 7.01.47

* Required Field

Enter Patient Information

• Gastric Bypass / RNY
• Sleeve Gastrectomy
• Other:
• Lap Band
• Revision Procedure

• Previous bariatric surgery * Yes No

• Is this procedure being performed due to complication of a previous bariatric procedure? * Yes No

Check all that apply:

• Staple line failure
• Obstruction
• Stricture
• Non-absorption resulting in hypoglycemia or malnutrition
• Weight loss of 20% or more below ideal body weight
• Band slippage
• Dilation of gastric pouch

• Has the member been compliant with the prescribed nutrition and exercise program? * Yes No

* Please include all supporting documentation:

Provide medically supervised diet, exercise, nutrition visits for 6 consecutive months: *

The weights need to be obtained in the physician office.

• 1. Date
• Height *
• Weight *
• BMI

• 2. Date
• Height *
• Weight *
• BMI

• 3. Date
• Height *
• Weight *
• BMI

• 4. Date
• Height *
• Weight *
• BMI

• 5. Date
• Height *
• Weight *
• BMI

• 6. Date
• Height *
• Weight *
• BMI

** This is a MULTIDISCIPLINARY SURGICAL PREPARATORY REGIMEN and MUST INCLUDE: Physician directed and dietician supervised weight program and include physician notes to include initial physician consult AND physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.

• Physician consult, directed diet, expercise, nutrition visits, and physician summary of member's progress at completion of program. * Yes No

• Nutritionist/Dietician Consultation AND Nutritionist/Dietician supervised weight loss visits: * Yes No

List a recorded weight and BMI for the 2 previous years *

• 1. Date
• Weight
• BMI

• 2. Date
• Weight
• BMI

• Is member recommended for bariatric surgery? * Yes No

• Does member have an adequate support system? * Yes No

• Any illicit drug/alchol use? * Yes No

• Smoking history? * Yes No

• Has the member smoked in the past 6 months? * Yes No

• Is member at least 12 months post-partum from today's date? * Yes No N/A

Please attach all supportive documentation documentation. *

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

• Checking this box will send a copy of your form to the email address provided.

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