Contact’s Name phone # fax # PART 1 (MUST BE …

1 bluecross blueshield of tennessee Bariatric Surgery precertification Request Form The BCBST Medical Policy for Bariatric Surgery for Morbid Obesity can be found at 1/12/2018 Does not apply to CoverKids. NOT ALL CONTRACTS INCLUDE OBESITY SURGERY BENEFITS. PLEASE CALL 1-800-225-8698 TO SPEAK WITH A BARIATRIC CASE MANAGER TO VERIFY REQUIREMENTS FOR EACH MEMBER. PLEASE FAX THIS COMPLETED FORM TO: 1-888-328-0394 OR MAIL TO: bluecross blueshield of tennessee Case Management 1 Cameron Hill Circle, Chattanooga, TN 37402-0017 This is a 3 part form. Please note the surgeon, attending physician, and psychologist have their own sections that are mandatory. Failure to complete all items may result in denial or delay of precertification authorization. If you are requesting revision, alteration, or reversal of a prior bariatric surgery, the forms are NOT required, but physician documented medical/or surgical complication must be documented in notes and imaging documents.

2 ** See bluecross blueshield of tennessee medical policy for bariatric surgery details. ** PART 1 (MUST BE COMPLETED BY REQUESTING BARIATRIC SURGEON): Date: _____ Member Name: _____ Member BCBS ID#: _____ Member Telephone: (home) _____ (work) _____ (cell) _____ To your knowledge, has this member previously had a Bariatric surgery? _____ If yes, please provide details including type of procedure, date of procedure, and other pertinent information: _____ Procedure(s) requested, including CPT code and ICD-10 diagnosis code(s): _____ Facility where surgery will be performed: _____ Tentative date of surgery: _____ Facility address, phone # and NPI # or BCBSTN Provider #: _____ Type of admission requested: (outpatient, 23 hour OBS, inpatient): _____ Bariatric surgeon s name, address, telephone, and BCBS of TN provider number <OR> NPI if applicable: _____ Bariatric surgeon s (printed) name: _____ Bariatric surgeon s signature: _____ Date: _____ I have reviewed this patient s clinical information and recommend that they have the requested Bariatric surgery.

3 By signing this documentation, I attest that the information contained above is correct, to the best of my knowledge, and clinical records substantiating this documentation are available for review, if requested. bluecross blueshield of tennessee Bariatric Surgery precertification Request Form The BCBST Medical Policy for Bariatric Surgery for Morbid Obesity can be found at 1/12/2018 PART 2 (MUST BE COMPLETED BY ATTENDING PHYSICIAN, SOMEONE OTHER THAN BARIATRIC SURGEON OR HIS/HER ASSOCIATES): Date: _____ Member Name: _____ Member BCBS ID#: _____ Member phone : (home) _____ (work) _____ (cell) _____ Document adherence to a non-surgical weight loss program ( dietary management, behavioral modification) and /or exercise program within two (2) years of request for surgery with participation for a minimum of 6 months: Date began: _____ and beginning weight: _____ Detail specifically what was being done for weight loss program: _____ _____ date program ended: _____ weight when program ended: _____ Current weight: Date.

4 _____ Weight: _____ Height: _____ BMI: _____ Has this member been able to achieve and / or maintain adequate weight loss ( 10-percent of initial body weight) by conservative means? Yes _____No _____ List (or attach) ALL members current diagnoses and past medical history: _____ _____ Please list or attach a list of ALL current medications: _____ _____ If BMI to please list (or attach) pertinent labs, DME (C-Pap, etc), or testing as needed to support Class 2 Obesity related co-morbidity: _____ _____ Attending physician s name (printed), address, telephone, and BCBS of TN provider number: _____ I have reviewed this patient s clinical information and recommend that they have the requested Bariatric surgery. By signing this documentation, I attest that the information contained above is correct, to the best of my knowledge, and those clinical records substantiating this documentation are available for review, if requested.

5 Attending physician s signature (Cannot be Nurse Practitioner or Physician s Assistant): _____ Date: _____ bluecross blueshield of tennessee Bariatric Surgery precertification Request Form The BCBST Medical Policy for Bariatric Surgery for Morbid Obesity can be found at 1/12/2018 PART 3 (MUST BE COMPLETED BY PSYCHIATRIST OR PSYCHOLOGIST WHO COMPLETED THE COMPREHENSIVE PSYCHOSOCIAL BEHAVIORAL EVALUATION): Member Name: _____ Member BCBS ID#: _____ NOTE: Per BCBST Medical Policy this may not be completed by licensed clinical social worker, behavioral health nurse practitioner, or licensed professional counselor. Form must be completed by psychiatrist or psychologist. Current (within last 5 years) psychiatric diagnosis: _____ _____ Clinical interview/evaluation that included discussion of reasons (beyond weight loss) for seeking bariatric surgery, current eating behaviors, required lifestyle changes and post-operative expectations has been completed by the psychiatrist or psychologist?

6 Yes _____ No _____ Date of interview/evaluation _____ Commonly used psychological testing has value in determining when individuals present information in the interview that is overly favorable. What specific psychological test and/or assessment tool [Possible choices: Minnesota Multiphasic Personality Inventory -2 , MMPI -2 - Restructured Form , or Millon Behavioral Medicine Diagnostic with bariatric norms] was administered and evaluated? _____ Date of psychological test _____ In your professional opinion is this individual able and willing to comply with the required dietary and behavioral modifications following surgery, as evidenced by the interview/evaluation and the psychological testing: Yes _____ No _____ Professional recommendation: o Yes; Cleared for bariatric surgery, without concerns o Yes; Cleared for bariatric surgery, recommend post-procedure follow-up o No; Not cleared for bariatric surgery Psychologist/Psychiatrist (printed) name: _____ Psychologist/Psychiatrist signature: _____ By signing this documentation, I attest that the information contained above is correct, to the best of my knowledge, and clinical record substantiating this documentation are available for review, if requested.

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