Alabama Medicaid Agency Nutritional Assessment/Counseling, Pharmaceutical Therapy Bariatric Surgery Adults: Medicaid does not cover dietitians except for recipients under 21 years of age. CPT Codes: 99401-99402 EPSDT: Diet instruction performed by a physician is considered part of a routine visit EPSTD screenings will be covered only if the provider is enrolled in that program. Screenings are not subjected to prior authorization. authorization required. PA requirements not specified beyond PA form. Xenical is the only currently covered. To receive prior authorization for Xenical®, the patient must be 18 years of age or older and have at least one of the following primary medical diagnoses: Diabetes mellitus Hypertension Hyperlipidemia Renewal requests require the patient’s previous and current weights (in pounds). Continued weight loss must be documented for renewals. There must be documentation in the patient record to support failure with prior physician supervised exercise/diet regimen(s) of at least 6 months duration. Documentation must also show that adjuvant therapy is planned. Medical justification may include peer-reviewed literature, medical record documentation, or other information specifically requested. Approval may be for up to 3 months with initial request, and up to 6 months for each subsequent request to a total approval period not to exceed 2 years for the recipient. Prior authorization required. Must be within 18 and 64 years of age. Must meet specific medical criteria and PA or the surgery will be considered cosmetic and will not be covered by Medicaid. Specific prior authorization criteria not found.
Obesity services outside of mandated EPSDT services are not explicitly mentioned. All requests for bariatric surgery must be prior authorized. This includes the surgeon, assistant surgeon (if medically necessary), anesthesiologist, and facility. Requests for prior authorizations of bariatric surgery must be submitted in writing. Specific prior authorization criteria not found. DISTRICT OF COLUMBIA Department of Health Care Finance Nutritional Assessment/Counseling Pharmaceutical Therapy Bariatric Surgery Adults: Not explicitly mentioned CPT Codes: 96151-96155, 99401 - 99404, 99411, S9470, S9445, S9452, 97802-97804 EPSDT: Obesity services outside of mandated EPSDT services are not explicitly mentioned. Excluded drugs include: Anti-obesity drugs Prior authorization required. Gastric bypass requires written justification and prior authorization. Specific prior authorization criteria not defined.
Obesity services are mentioned but not explicitly detailed; focuses entirely on preventive action Payment for this service may be made only in cases in which the physician determines that obesity is exogenous in nature, the recipient has had the benefit of other therapy with no success, endocrine disorders have been ruled out, and the body mass index (BMI) is 40 or higher, or 35 to 39.9 with serious medical complications. INDIANA Office of Medicaid Policy and Planning Nutritional Assessment/Counseling Pharmaceutical Therapy Bariatric Surgery, Adults: Not explicitly mentioned. CPT Codes: 96150-96155, 99401, 99403-99404, 99411-99412, 97802-97804, 99078, S0315- S0316, S9445-S9446, S9449, S9451-S9452, S9470, EPSDT: Obesity services outside of mandated EPSDT services are not explicitly mentioned. Excluded drugs include: Anorectics or any agent used to promote weight loss Prior authorization required. Bariatric surgery is recognized as medically necessary when used for the treatment of morbid obesity. As of June 1st 2014, Sleeve gastrectomy will be covered. All of bariatric surgery are subject to the following conditions. Scope and duration of failed weight loss therapy must meet the following criteria. Morbid obesity has persisted for at five years duration, and b. Physician-supervised
Obesity services outside of mandated services are not explicitly mentioned however, Licensed dietitians employed by or under contract with physicians may provide nutritional counseling services to recipients age 20 and under. KANSAS Kansas Health Policy Authority Nutritional Assessment/Counseling Pharmaceutical Therapy Bariatric Surgery, Adults: Provider Manual was inaccessible with weblink on state Medicaid agencies website CPT MediKan (Traditional FFS Medicaid): None EPSDT: Provider Manual was inaccessible with weblink on state Medicaid agencies website None found. Prior authorization required. Open or laparoscopic Roux-en-Y bypass (RYGB), open or laparoscopic biliopancreatic diversion (BPD), with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB) will be considered medically necessary when selection criteria are met. Must meet either 1 (adults) or 2 (adolescents): 1. For adults aged 18 or older, presence of severe obesity that has persisted for at least the last 2 years (24 months), documented in contemporaneous clinical records, defined as any one of the following: Body mass index (BMI) exceeding 40
Adults: Not explicitly mentioned. CPT Codes: 96150-96155, 97802-97804 EPSDT: Obesity services outside of mandated EPSDT services are not explicitly mentioned. Excluded drugs include: Anorexics – Medicaid does not reimburse for anorexics with the exception of orlistat; Medicaid will provide reimbursement to outpatient pharmacies for orlistat prescriptions based on the following criteria: An authorized prescriber has hand written the prescription - no facsimiles allowed; Patient is twelve years of age or older; Only original prescriptions—no refills are allowed; Maximums of ninety (90) capsules and thirty (30) days supply; Patient has a documented current body mass index (BMI) of twenty-seven (27) or greater and the prescriber had identified the BMI, in his/her handwriting, on the dated prescription or a dated and signed attachment to the prescription; Patient has other risk factors warranting the use of Orlistat and the prescriber has identified an approved ICD-9-CM diagnosis code in his/her handwriting, on the dated prescription or a dated and signed attachment to the prescription; and No provisions for override of the prospective drug utilization edits, i.e., early refill (ER) and duplicate drug (ID) editing. Refer to source for full criteria Requires authorization. Louisiana Medicaid covers bariatric or weight loss surgery as an option only after a comprehensive and sustained program of diet and exercise with or without pharmacologic measures has been unsuccessful over time. Bariatric surgery may consist of open or laparoscopic procedures that revise the gastro-intestinal anatomy to restrict the size of the stomach and/or reduce absorption of nutrients. Authorization: Surgeons who perform bariatric surgery must obtain prior authorization through the fiscal intermediary’s Prior Authorization (PA) Unit. The PA request shall include a thorough multidisciplinary evaluation within the previous 12 months. NOTE: A physician letter documenting recipient qualifications and medical necessity must accompany the PA request and must include confirmatory evidence of co-morbid condition(s). Photographs must be submitted with the request for consideration of bariatric surgery.
MISSISSIPPI Division of Medicaid Nutritional Assessment/Counseling Pharmaceutical Therapy Bariatric Surgery Adults: Not explicitly mentioned. CPT Codes: None. EPSDT: Primary care providers or other health centers that provide primary care services must offer to conduct periodic and medically necessary interperiodic visits to screen all Medicaid-eligible children and youth up to age twenty-one (21) in accordance with the EPSDT Periodicity Schedule as recommended by the American Academy of Pediatrics, and must provide or refer such beneficiaries to assessment, diagnosis, and treatment services. Treatment guidelines not found. Pharmacy program exclusions include: when used for anorexia, weight loss, or weight gain. Non-covered services include: Gastric surgery including any technique or procedure for the treatment of obesity or weight control, regardless of medical necessity. MISSOURI MO HealthNet Division, Department of Social Services Nutritional Assessment/Counseling Pharmaceutical Therapy Bariatric Surgery Adults: The treatment of obesity is noncovered unless the treatment is an integral and necessary part of a course of treatment for a concurrent or complicating medical condition. CPT Codes: 99402, S0315-S0316 EPSDT: used to promote weight loss are excluded under MO HealthNet. Morbid obesity treatment: Morbid obesity, as defined by the American Medical Association (AMA) is a Body Mass (BMI) greater than 40. The treatment of obesity is covered by MO HealthNet (MHD) when the treatment is an integral and necessary course of treatment for a concurrent or complicating medical treatment. The following codes for bariatric surgery, gastric bypass, gastroplasty, and laparoscopy are covered codes by MHD for patients with a BMI of greater than 40 and a co-morbid condition(s).
nutritional issues. These children may benefit from intense nutritional counseling in combination with mental health and family counseling support. Other obesity services outside of mandated EPSDT services are not explicitly mentioned. hospital will be reimbursed for bariatric surgical services for Medicaid Fee for Service and managed care beneficiaries. NORTH CAROLINA Department of Health and Social Services Nutritional Assessment/Counseling Pharmaceutical Therapy Bariatric Surgery Adults: Not explicitly mentioned CPT Codes: 96150-96151, 99404, 99412, 97802-97803 Obesity services outside of mandated EPSDT services are not explicitly mentioned. The following is a list of services not covered by Medicaid or NCHC when billed under the Outpatient Pharmacy Program: Weight loss and weight gain Prior authorization required. NC Medicaid (Medicaid) recipients shall be enrolled on the date of service and may have service restrictions due to their eligibility category that would make them ineligible for this service. NC Health Choice (NCHC) recipients, ages 6 through 18 years of age, shall be enrolled on the date of service to be eligible, and shall meet policy coverage criteria, unless otherwise specified.
EPSDT: Obesity services outside of mandated EPSDT services are not explicitly mentioned. gastroplasty for morbid obesity, gastric stapling or ileojejunal except when all other types of treatment of morbid obesity have failed RHODE ISLAND Department of Human Services Nutritional Assessment/Counseling Pharmaceutical Therapy Bariatric Surgery Adults: Not explicitly mentioned CPT 97802-97804 Obesity services outside of mandated services are not explicitly mentioned. Prior Authorization is required for all drugs not included within the scope of the Medical Assistance Program. A prior authorization form must be signed by the prescribing provider and forwarded to the pharmacy where the prescription is to be filled. The pharmacist will then submit to the Medical Assistance Program this form for approval. Approval will be granted on the basis of the required information that was supplied. This prior approval will last for the duration of the prescription. In general, the types of drugs not included are the following: Anorexiants (all types, limited to a three-month approval only) Prior authorization required Bariatric surgery is performed for long term weight management in individuals diagnosed with severe or morbid obesity. Two categories of procedures are applicable: Gastric-restrictive procedures designed to create a small gastric pouch resulting in weight loss produced by early satiety and decreased caloric intake. Malabsorptive procedures designed to result in weight loss by altering the normal transit of food through the intestine and subsequent malabsorption. Combination procedures may incorporate elements of both therapeutic processes. Refer to source for full criteria
TENNCare Nutritional Assessment/Counseling Pharmaceutical Therapy Bariatric Surgery Adults: Services, products, and supplies that are specifically excluded from coverage under the TennCare program. Weight loss or weight gain and physical fitness programs including, but not limited to: Dietary programs of weight loss programs, including, but not limited to, Optifast, Nutrisystem, and other similar programs or exercise programs Food supplements will not be authorized for use in weight loss programs or for weight gain Health membership fees (e.g., YMCA) Marathons, activity and entry fees Swimming pools CPT Codes: TennCare is a series of managed care plans with individual fee schedules (individuals should contact their respective MCO provider as coverage may vary). Obesity services outside of mandated services are not explicitly mentioned. Excluded products include: Agents when used for anorexia, weight loss, or weight gain Bariatric Surgery, defined as surgery to induce weight loss is covered when medically necessary and in accordance with clinical guidelines established by the Bureau of TennCare. Acceptable bariatric surgical procedures include Roux- Gastric and Biliopancreatic Diversion with Duodenal Switch. Gastric stapling is not an acceptable bariatric procedure. Health and Human Services Commission Nutritional Assessment/Counseling, Pharmaceutical Therapy Bariatric Surgery Adults: Medical nutrition counseling services for the diagnosis of obesity without a comorbid condition is not a benefit. Exclusions: Medicaid may deny a request if it determines the drug is included in one or more of the following classes: 1)Amphetamines, when used for weight loss, and obesity control Bariatric surgery is considered medically necessary when used as a means to treat covered medical conditions that are caused or significantly worsened by the client’s obesity in cases where these morbid conditions cannot adequately be treated by standard