Current through Register Vol. 24-18, September 15, 2024
(1) The agency
covers medically necessary bariatric surgery for eligible clients.
(2) Bariatric surgery must be performed in a
hospital with a bariatric surgery program, and the hospital must be:
(a) Located in the state of Washington or
approved border cities (see WAC
182-501-0175); and
(b) Meet the requirements of WAC
182-550-2301.
(3) If bariatric surgery is
requested or prescribed under the EPSDT program, the agency evaluates it as a
covered service under EPSDT's standard of coverage that requires the service to
be:
(a) Medically necessary;
(b) Safe and effective; and
(c) Not experimental.
(4) The agency authorizes payment for
bariatric surgery and bariatric surgery-related services in three stages:
(a) Stage one - Initial assessment of
client;
(b) Stage two - Evaluations
for bariatric surgery and successful completion of a weight loss regimen;
and
(c) Stage three - Bariatric
surgery.
Stage one - Initial assessment
(5) Any agency-enrolled provider
who is licensed to practice medicine in the state of Washington may examine a
client requesting bariatric surgery to ascertain if the client meets the
criteria listed in subsection (6) of this section.
(6) The client meets the preliminary
conditions of stage one when:
(a) The client
is:
(i) Twenty-one through fifty-nine years
of age; or
(ii) Eighteen through
twenty years old for laparoscopic adjustable gastric banding (LAGB)
only;
(b) The client has
a body mass index (BMI) of thirty-five or greater;
(c) The client is not pregnant. (Pregnancy
within the first two years following bariatric surgery is not recommended. When
applicable, a family planning consultation is highly recommended prior to
bariatric surgery);
(d) The client
is diagnosed with one of the following:
(i)
Diabetes mellitus;
(ii)
Degenerative joint disease of a major weight bearing joint(s) (the client must
be a candidate for joint replacement surgery if weight loss is achieved);
or
(iii) Other rare comorbid
conditions (such as pseudo tumor cerebri) in which there is medical evidence
that bariatric surgery is medically necessary and that the benefits of
bariatric surgery outweigh the risk of surgical mortality; and
(e) The client has an absence of
other medical conditions such as multiple sclerosis (MS) that would increase
the client's risk of surgical mortality or morbidity from bariatric
surgery.
(7) If a client
meets the criteria in subsection (6) of this section, the provider must request
prior authorization from the agency before referring the client to stage two of
the bariatric surgery authorization process. The provider must attach a medical
report to the request for prior authorization with supporting documentation
that the client meets the stage one criteria in subsections (5) and (6) of this
section.
(8) The agency evaluates
requests for covered services that are subject to limitations or other
restrictions and approves such services beyond those limitations or
restrictions when medically necessary, under the provisions of WAC
182-501-0165 and
182-501-0169.
Stage two - Evaluations for bariatric surgery and
successful completion of a weight loss regimen
(9) After receiving prior authorization from
the agency to begin stage two of the bariatric surgery authorization process,
the client must:
(a) Undergo a comprehensive
psychosocial evaluation performed by a psychiatrist, licensed psychiatric ARNP,
or licensed independent social worker with a minimum of two years postmasters'
experience in a mental health setting. Upon completion, the results of the
evaluation must be forwarded to the agency. The comprehensive psychosocial
evaluation must include:
(i) An assessment of
the client's mental status or illness to:
(A)
Evaluate the client for the presence of substance abuse problems or psychiatric
illness which would preclude the client from participating in presurgical
dietary requirements or postsurgical lifestyle changes; and
(B) If applicable, document that the client
has been successfully treated for psychiatric illness and has been stabilized
for at least six months and/or has been rehabilitated and is free from any drug
and/or alcohol abuse and has been drug and/or alcohol free for a period of at
least one year.
(ii) An
assessment and certification of the client's ability to comply with the
postoperative requirements such as lifelong required dietary changes and
regular follow-up.
(b)
Undergo an internal medicine evaluation performed by an internist to assess the
client's preoperative condition and mortality risk. Upon completion, the
internist must forward the results of the evaluation to the agency.
(c) Undergo a surgical evaluation by the
surgeon who will perform the bariatric surgery (see subsection (13) of this
section for surgeon requirements). Upon completion, the surgeon must forward
the results of the surgical evaluation to the agency and to the licensed
medical provider who is supervising the client's weight loss regimen (refer to
WAC 182-531-1600(9)(d)(ii)
).
(d) Under the supervision of a
licensed medical provider, the client must participate in a weight loss regimen
prior to surgery. The client must, within one hundred and eighty days from the
date of the agency's stage one authorization, lose at least five percent of his
or her initial body weight. If the client does not meet this weight loss
requirement within one hundred and eighty days from the date of the agency's
initial authorization, the agency will cancel the authorization. The client or
the client's provider must reapply for prior authorization from the agency to
restart stage two. For the purpose of this section, "initial body weight" means
the client's weight at the first evaluation appointment.
(i) The purpose of the weight loss regimen is
to help the client achieve the required five percent loss of initial body
weight prior to surgery and to demonstrate the client's ability to adhere to
the radical and lifelong behavior changes and strict diet that are required
after bariatric surgery.
(ii) The
weight loss regimen must:
(A) Be supervised
by a licensed medical provider who has a core provider agreement with the
agency;
(B) Include monthly visits
to the medical provider;
(C)
Include counseling twice a month by a registered dietician referred to by the
treating provider or surgeon; and
(D) Be at least six months in
duration.
(iii)
Documentation of the following requirements must be retained in the client's
medical file. Copies of the documentation must be forwarded to the agency upon
completion of stage two. The agency will evaluate the documentation and
authorize the client for bariatric surgery if the stage two requirements were
successfully completed.
(A) The provider must
document the client's compliance in keeping scheduled appointments and the
client's progress toward weight loss by serial weight recordings. The client
must lose at least five percent of his or her initial body weight and must
maintain the five percent weight loss until surgery;
(B) For diabetic clients, the provider must
document the efforts in diabetic control or stabilization;
(C) The registered dietician must document
the client's compliance (or noncompliance) in keeping scheduled appointments,
and the client's weight loss progress;
(D) The client must keep a journal of active
participation in the medically structured weight loss regimen including the
activities under (d)(iii)(A), (d)(iii)(B) if appropriate, and (d)(iii)(C) of
this subsection.
(10) If the client fails to complete all of
the requirements of subsection (9) of this section, the agency will not
authorize stage three - Bariatric surgery.
(11) If the client is unable to meet all of
the stage two criteria, the client or the client's provider must reapply for
prior authorization from the agency to reenter stage two.
Stage three - Bariatric surgery
(12) The agency may withdraw
authorization of payment for bariatric surgery at any time up to the actual
surgery if the agency determines that the client is not complying with the
requirements of this section.
(13)
A surgeon who performs bariatric surgery for medical assistance clients must:
(a) Have a signed core provider agreement
with the agency;
(b) Have a valid
medical license in the state of Washington; and
(c) Be affiliated with a bariatric surgery
program that meets the requirements of WAC
182-550-2301.
(14) For hospital requirements for
stage three - Bariatric surgery, see WAC
182-550-2301.
Statutory Authority:
RCW
41.05.021. WSR 13-14-016, §182-531-1600,
filed 6/21/13, effective 7/22/13. WSR 11-14-075, recodified as
§182-531-1600, filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.04.050,
74.08.090,
74.09.530, and
74.09.700. WSR 06-24-036, §
388-531-1600, filed 11/30/06, effective 1/1/07. Statutory Authority:
RCW
74.08.090,
74.09.520. WSR 05-12-022, §
388-531-1600, filed 5/20/05, effective 6/20/05; WSR 01-01-012, §
388-531-1600, filed 12/6/00, effective
1/6/01.
