OHCA Policies and Rules
|317:30-5-137.||Eligible providers to perform bariatric surgery|
The Oklahoma Health Care Authority (OHCA) covers bariatric surgery under certain conditions as defined in this section. Bariatric surgery is not covered for the treatment of obesity alone. To be eligible for reimbursement, bariatric surgery providers must be certified by the American College of Surgeons (ACS) as a Level I Bariatric Surgery Center or certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (BSCOE) or the surgeon and facility are currently participating in a bariatric surgery quality assurance program and a clinical outcomes assessment review. All qualifications must be met and approved by the OHCA. Bariatric surgery facilities and their providers must be contracted with OHCA.
Documentation must be submitted to the OHCA prior authorization unit prior to beginning any treatment program to ensure all requirements are met and the member is an appropriate candidate for bariatric surgery. This is the first of two prior authorizations required to approve a member for bariatric surgery. To be considered, members must meet the following candidacy criteria:
(1) be between 18 and 65 years of age;
(2) have body mass index (BMI) of 35 or greater;
(3) be diagnosed with one of the following:
(A) diabetes mellitus;
(B) degenerative joint disease of a major weight bearing joint(s). The member must be a candidate for joint replacement surgery when optimal weight loss is achieved; or
(C) a rare co-morbid condition in which there is medical evidence that bariatric surgery is medically necessary to treat such a condition and that the benefits of bariatric surgery outweigh the risk of surgical mortality.
(4) have presence of obesity that has persisted for at least 5 years;
(5) have attempted weight loss in the past without successful long term weight reduction, which must be documented by a physician;
(6) have absence of other medical conditions that would increase the member's risk of surgical mortality or morbidity; and
(7) the member is not pregnant or planning to become pregnant in the next two years.
(a) After receiving member candidacy prior authorization from OHCA and the determination that member candidacy requirements are met (see OAC 317:30-5-137.1), the primary care provider coordinates a pre-operative assessment and weight loss process to include:
(1) a comprehensive psychosocial evaluation including:
(A) evaluation for substance abuse;
(B) evaluation for psychiatric illness which would preclude the member from participating in pre-surgical weight loss and evaluation program or successfully adjusting to the post surgical lifestyle changes;
(C) if applicable, documentation that the member has been successfully treated for a psychiatric illness and has been stabilized for at least six months; and
(D) if applicable, documentation that the member has been rehabilitated and is free from drug and/or alcohol for a period of at least one year.
(2) an independent medical evaluation performed by an internist experienced in bariatric medicine who is contracted with the OHCA to assess the member'
s operative morbidity and mortality risks.
(3) a surgical evaluation by an OHCA contracted surgeon who has credentials to perform bariatric surgery.
(4) participation in a six month weight loss program prior to surgery, under the supervision of an OHCA contracted medical provider. The member must, within 180 days from the initial or member candidacy prior authorization approval, lose at least five percent of member'
s initial body weight.
(b) When all requirements have been met, a prior authorization for surgery must be obtained from OHCA. This authorization can not be requested before the initial 180 day weight loss program has been completed.
(1) If the member does not meet the weight loss requirement in the allotted time the member will not be approved for bariatric surgery.
(2) The member'
s provider must restart the prior authorization process if this requirement is not met.
(c) The bariatric surgery facility or surgeon must, on an annual basis, provide to the OHCA the members statistical data which includes but is not limited to, mortality, hospital readmissions, re-operation, morbidity and average weight loss data.
(d) OHCA considers surgery to correct complications from bariatric surgery, such as obstruction or stricture, medically necessary.
(e) OHCA considers repeat bariatric surgery medically necessary for a member whose initial bariatric surgery was medically necessary, and member meets either of the following criteria:
(1) has not lost more than fifty percent of excess body weight two years following the primary bariatric surgery procedure and is in compliance with prescribed nutrition and exercise programs following the procedure; or
(2) failure due to dilation of the gastric pouch if the initial procedure was successful in inducing weight loss prior to the pouch dilation and the member is in compliance with prescribed nutrition and exercise programs following the initial procedure.
(f) OHCA may withdraw authorization of payment for the bariatric surgery at any time if the OHCA determines that the member or provider is not in compliance with any of the requirements.
|317:30-5-138.||General coverage [REVOKED]|
|317:30-5-139.||Member requirements [REVOKED]|
|317:30-5-140.||Coverage for children|
(a) Services, deemed medically necessary and allowable under federal Medicaid regulations, may be covered by the EPSDT/OHCA Child Health program even though those services may not be part of the OHCA Medicaid program. Such services must be prior authorized.
(b) Federal Medicaid regulations also require the state to make the determination as to whether the service is medically necessary and do not require the provision of any items or services that the state determines are not safe and effective or which are considered experimental.
Payment is made at the lower of the provider's usual and customary charge or the OHCA fee schedule for Medicaid compensable services.
Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.