Gastric surgery for weight loss is covered when it is an integral and necessary part of a course of treatment for another illness such as cardiac disease, respiratory disease, diabetes, or hypertension and the individual meets all of the following criteria:
- The individual is severely obese with Body Mass Index (BMI) over 40 and is at least 21 years of age.
- BMI = weight in kilograms (2.2 lbs/kg) divided by the square of height in meters (39.37 in./meter);
- There is a significant interference with activities of daily living.
- There is documented conservative (non-surgical) promotion of weight loss by a physician supervised weight loss program. Dietician consult is recommended, if available, and the individual must have documentation of 4 consecutive monthly visits with their primary care physician to monitor compliance with, and results of, a conservative weight loss program.
- The recipient is motivated and well-informed. The recipient is free of significant systemic illness unrelated to obesity, is not actively abusing drugs or alcohol, and does not use tobacco or if a tobacco user has discontinued use for 4 months documented in the medical record.
- It is medically and psychologically appropriate for the individual to have such surgery.
- At least one of the following must also be present:
- History of pain and limitation of motion in any weight-bearing joint or the lumbosacral spine as documented by physical examination; or
- Hypertension requiring medical therapy; or
- Congestive heart failure manifested by laboratory evidence or past evidence of vascular congestion such as hepatomegaly, peripheral edema, or pulmonary edema; or
- Chronic venous insufficiency with superficial varicosities in a lower extremity with pain on weight bearing and persistent edema; or
- Respiratory insufficiency or hypoxemia at rest; or
- Type II diabetes not adequately controlled by compliance with medical treatment; or
- Sleep apnea of at least moderate severity, documented by appropriate testing.
- The procedure will be performed at a Medicare approved Center of Excellence in South Dakota and if lap band/gastric banding procedure has been approved by the South Dakota Medical Assistance Program the follow-up adjustments must be performed by the surgeon who did the original surgery or a surgical partner in that practice.
67:16:01:06.02. Covered services must be medically necessary. Services covered under this article must be medically necessary. To be medically necessary, the covered service must meet the following conditions:
- It is consistent with the recipient's symptoms, diagnosis, condition, or injury;
- It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group;
- It is provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition;
- It is not furnished primarily for the convenience of the recipient or the provider; and
- There is no other equally effective course of treatment available or suitable for the recipient requesting the service which is more conservative or substantially less costly.
Documentation Requirements for Prior Authorization Requests:
- Prior Authorization Request Form
- Medical Documentation to support medical necessity which includes all co morbidities (history and physicals, discharge summaries, progress notes, specialty physician consults, etc.)
- Current psychological/psychiatric evaluation addressing appropriateness for potential bariatric surgery. These evaluations need to be completed by a psychologist, psychiatrist, CSW PIP, LPC-MH, or CNP-MH.
- Documentation which supports failure of conservative weight loss efforts for the past year managed by a physician (PCP). Please include all available documentation regarding weight loss attempts such as the dictation from a dietitian if one has been seen, clinic progress notes, food and exercise logs, etc.
- Current height, weight, and BMI
- Surgical Consultation, including documentation for choice of surgical procedure and why.
Please note: Individuals with Medicare must seek a coverage determination from Medicare. Medicaid’s coverage will be dependant on Medicare’s determination.
Submit completed documentation to:
- Department of Social Services
Division of Medical Services
700 Governors Drive
Pierre, SD 57501
- Phone: 605-773-3495
- Fax: 605-773-5246
National Institutes of Health Obesity
Preventive Services Task Force