PH - NEW Prior Authorization Requirements for Bariatric Surgery

September 8, 2022

From Priority Health:

 

We share your goal of ensuring your patients, our members, get the right care at the right time.  

 

To support this goal within bariatric surgery, we’ve expanded the provider types that can complete the pre-surgical psychological evaluation. 

 

We’ve also clarified expected components of the psychological evaluation. Starting October 31, we’ll require an evaluation to cover specific areas related to a member’s drug use habits to meet prior authorization requirements.  

 

What new areas will the evaluation need to cover? 

A sample evaluation that meets our requirements is available in medical policy #91595 – Surgical Treatment of Obesity. You don’t need to use this exact form if your evaluation includes the same information in your EHR. 

 

Why are we updating the evaluation requirements? 

Bariatric surgery is a significant, life-altering procedure, and we’ve always required a pre-surgical psychological evaluation as part of the prior authorization process. When these evaluations didn’t provide enough detail on a member’s drug use habits, we’d often need to deny due to possible adverse effects. 

 

The updated evaluation requirements will ensure we: 

 

  • Fully understand the member’s drug use habits 
     
  • Determine whether that drug use rises to the level of a diagnosed disorder, such as substance use disorder 
     
  • Confirm whether the drug use is impacting the member right now, rather than in the past 
     
  • Only deny or require substance use testing for the procedure when absolutely necessary 

 

Who can conduct these evaluations? 

A provider with a master’s degree or doctorate can complete these pre-surgical evaluations. This is an expansion as previously, only a psychologist could complete the evaluation. 

 

We appreciate your commitment to the health and wellbeing of our members.