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317:30-5-137.2.General coverage

[Issued 12-03-09]
(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.

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.