Does not apply to TennCare, please refer to the TennCare policy.
Does not apply to the State of Tennessee Member Contract.
Patient Name: ___________________________Age: ___________Date: ____________________
Provider's name: __________________________________________________________________
Provider's address: ________________________________________________________________
Provider's phone number: ___________________________________________________________
Diagnosis code(s): ________________________________________________________________
CPT, HCPCS, or ICD-9 procedure code(s): ____________________________________________
Date Services are to be rendered: ____________________________________________________
Member's ID:_____________________________________________________________________
(All the information listed below is required for medical appropriateness criteria determination)
Please attach the information below to the appropriate form for your request (e.g., predetermination, precertification) and line of business (e.g., Commercial).
Note: BlueCross BlueShield of Tennessee reserves the right to request additional information.
Name of the specific bariatric surgical procedure.
Is the individual 18 years old or older?
Does the individual have a diagnosis of morbid obesity that has persisted for at least 5 years?
What is the individual's body mass index (BMI) and height / weight?
List any obesity related co-morbidities that will reduce the individual's life expectancy.
Does the individual have three (3) or more cardiac risk factors?
Please list them.
The following information identifies the attempt at conservative management, which must be within 2 years of the planned surgery. The attending physician recommending the surgery must submit the information below (e.g., patient recorded information, structured program records) and the attending physician must be someone other than the surgeon and his/her associates.
Please list the methods used by the individual use to lose weight? (e.g., pharmacotherapy, Weight Watchers®, low fat diets, low caloric diets, exercise, life-style modification.)
Please provide the specific information (with documentation) requested below.
Complete the following for each drug listed.·
Has the individual tried pharmacotherapy?
List the medication
Date started
Date ended
Weight when started
Weight when ended
Individual's explanation for failure
Complete the following for each program listed.
List any structured exercise programs the individual has been involved with.
Name of program
Date began
Date ended
Weight when entering program
Weight when left program
Individuals explanation of failure
Name of physician or registered dietician overseeing the program
Complete the following for each program listed.
List any structured weight loss programs the individual has attempted to increase physical activity.
Name of program
Date began
Date ended
Weight when entering program
Weight when left program
Individual's explanation for failure
If individual has not attempted any type of structured weight loss program, please list the types of diets the individual has attempted and who followed the individual with the diet.
Type of diet
Date began
Date ended
Weight when began diet
Date when stopped diet
Individual's explanation for failure
Name of physician who monitored progress
Physician's explanation for failure·
Has the member successfully lost 10% of initial body weight as required per medical policy for bariatric surgery?
Psychological Evaluation·
Psychiatrist/Psychologist must submit all of the following, including each test result:
Documentation of the individual's willingness to comply with both the pre and postoperative treatment plans; and
Interview/evaluation results; and
Minnesota Multiphasic Personality Inventory (MMPI 2); and
The Eating Disorder Inventory (EDI-2) or the Eating Attitudes Test (EAT-26)
NOTE: If the above (Interview/evaluation, MMPI 2, EDI-2 or EAT-26, or the Psychological evaluation) provides a suggestion of cognitive slippage or psychosis, a predictive test (e.g., thematic apperception test (TAT) or the Rorschach test) is required.
BlueCross BlueShield of Tennessee Use Only