Health Plans, Inc. — Corporate Headquarters • PO Box 5199 • Westborough, MA 01581 • 800-532-7575

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BariatricSurg_PriorAuthRequestForm_010418

Bariatric Surgery Prior Authorization Request Form

Member Name:

Member ID#: DOB: Age:

Requesting Surgeon: Requesting Surgeon TIN #:

Facility Name/Location: Facility NPI:

Setting: Inpatient Day Surgery Planned Date of Service:

Designated Harvard Pilgrim Health Care Center of Excellence: Yes No

Current Body Mass Index (BMI) (at minimum must be ≥ 35): Height: Weight:

Describe history of failed weight loss attempts:

Co-morbid conditions (required for BMI < 40 and ≥ 35) (check all that apply):

Diabetes Mellitus Hypertension requiring medication treatment Obstructive Sleep Apnea failing other treatment (e.g. CPAP) or associated with pulmonary hypertension Coronary artery disease Obesity hypoventilation syndrome or other obesity related cardiopulmonary conditions Pseudotumor cerebri Severe weight bearing back or joint disease, and with surgical treatment planned but for the obesity

Planned Procedure:

Short Limb Gastric Bypass/Roux-en-Y (RYGB)- Roux Limb ≤ 150cm [laparoscopic 43644; open 43846] Biliopancreatic Diversion with Duodenal Switch (BPD/DS) [laparoscopic 43845; open 43845] Vertical Banded Gastroplasty (VBG) [43842] Laparoscopic Adjustable Gastric Banding (e.g., LAP-BAND®, REALIZE™ Adjustable Gastric Band) [43770] Laparoscopic Sleeve Gastrectomy [43775] Removal and Revision [43771, 43772, 43773, 43774, 43848, 43886, 43887, 43888] Other:

Pre-operative Evaluation Completed (to be completed within the past 6 months):

Medical Evaluation Date completed: Nutrition Evaluation Date completed:

Behavioral Health Evaluation Date completed: Surgical Evaluation Date completed:

Health Plans, Inc. — Corporate Headquarters • PO Box 5199 • Westborough, MA 01581 • 800-532-7575

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BariatricSurg_PriorAuthRequestForm_010418

To be completed by Bariatric Surgeon:

I, verify that I have personally reviewed these four pre-operative reports. (print name of Bariatric Surgeon)

Check one of the following:

These pre-operative reports contain no contraindications to bariatric surgery or any indications of patient inability to comply with postoperative instructions, or:

The following contraindication to bariactric surgery or indication of patient inablility to comply with postoperative instructions was identified, but the patient was deemed appropriate for bariatric surgery (please explain):

_________________________________________________________________ ________________________________

Signature of Bariatric Surgeon Date

Fax completed form to 508-756-1382