Changes to our medical policy on the surgical treatment of obesity

Effective August 31, we're making changes to our medical policy on the surgical treatment of obesity. These changes will make us compliant with Medicaid requirements and to provide further clarification to providers.

What is being updated

Psychosocial evaluation requirement: Criteria updated to reflect that a comprehensive psychosocial evaluation conducted by a licensed behavioral specialist (psychiatrist for Medicaid/Healthy Michigan Plan members) is required to be considered for primary bariatric or revisional bariatric surgery.

Preoperative psychiatric clearance requirement: For members who have severe psychopathology who are currently under the care of a psychiatrist, or who are on psychotropic medications, preoperative psychiatry clearance is necessary in order to determine informed consent and an ability to comply with pre- and post-operative regimen.

Documentation of negative drug urine screens: For members who have a history of illegal drug use, there must be documented compliance with abstinence, including negative monthly urine drug screens for at least six continuous months.

Documentation of no tobacco use: For members who have a current history of smoking or smoking within the past two years, documented compliance demonstrating smoking cessation, including two negative cotinine levels within a 30-day time period, is required. These levels must be taken no earlier than 6 weeks prior to requesting bariatric surgery.

Life-endangering co-morbidity requirement: The criteria for a BMI > 35 is updated to reflect that at least one "life-endangering" obesity-related co-morbidity is required, and the criteria clearly defines what is considered a life-endangering co-morbidity.

Plan types affected

These changes will affect all plan types. Medicaid/Healthy Michigan Plan members will be uniquely affected as noted.

Who to contact for help with referrals to psychiatrists

Our Find a Doctor tool will help you find psychiatrists who accept Priority Health Medicaid plans. Please be advised that, since psychiatry is a specialty, there may be extended wait times for an appointment.

Questions?

See the pending medical policy. When these changes go into effect, we'll also update the page at Procedures and services > Medical/surgical > Obesity management.