Effective June 28, 2024: Clinical Policies

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Bariatric Surgery (CP.MP.37)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS)

Policy updates include:

• Removed high risk for type 2 DM in Criteria I.A.1.a.ii.c)i)
• Changed Criteria I.A.1.a.ii.c)ii) from poorly controlled hypertension to hypertension
• Removed severe urinary incontinence from Criteria I.A.1.a.ii.c)xii)
• Updated verbiage in Criteria I.A.1.a.ii.c)xiii) to bone and joint diseases
• Removed idiopathic intracranial hypertension from Criteria I.A.1.a.ii.c)xiv) since duplicative since pseudotumor cerebri is in criteria
• Added chronic kidney disease in Criteria I.A.1.a.ii.c)xiii)
• Added infertility in Criteria I.A.1.a.ii.c)xiv)
• Added polycystic ovarian syndrome in Criteria I.A.1.a.ii.c)xv)
• Clarified verbiage in Criteria I.A.1.b
• Updated Criteria I.A.1.b.ii.d) to state nonalcoholic fatty liver disease or nonalcoholic steatohepatitis
• Criteria Clarified verbiage in Criteria I.B.1. and in Criteria I.B.1.a
• Updated Criteria I.B.1.b.iv. from glomerular filtration rate (GFR) < 30 mL/min-1 to GFR < 60 mL/min-1
• Added Criteria I.B.1.b.vii. to include unstable angina
• Added Criteria I.B.1.b.viii. to include recent myocardial infarction (within the past 60 days)
• Updated Criteria I.B.4. to include thiamine, calcium, and fat-soluble vitamins
• In I.B.5., removed requirement for monthly nutritional counseling
• Updated verbiage to Criteria I.B.9. to state gastrointestinal (GI) screening and evaluation for clinically significant GI symptoms with documentation of needed treatment prior to bariatric surgery
• Removed Criteria I.B.10. for Helicobacter pylori screening
• Minor rewording in Criteria I.B.11
• Updated Criteria III.B. to include other names of procedure for clarification
• Minor rewording in Criteria III.K
• Removed one-anastomosis gastric bypass in Criteria III.L. since duplicative