Prior Authorization Request for Bariatric Surgery Request Form

Medical Policy 7.01.47

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* Required Field

Enter Patient Information

- -
  • Gastric Bypass / RNY
  • Sleeve Gastrectomy
  • Other:
  • Lap Band
  • Revision Procedure
  • Yes No
  • 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
  • Yes No

* Please include all supporting documentation:

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

  • Yes No

** 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.

  • Yes No
  • Yes No

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

  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • 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.

If you experience issues submitting this form, please print and fax it to (816) 817-8211.

If you have questions, contact Blue KC at (816) 395-3989.

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Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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