medicaid ffs treatment of obesity interventions 2014 (final) - stop obesity...

MEDICAID FEE-FOR-SERVICE

TREATMENT OF OBESITY

INTERVENTIONS

Compiled By:Christine Petrin

Kaushika PrakashScott Kahan, M.D., M.P.H.Christine Gallagher, M.P.A.

50 State &

District of

Columbia

Survey

- 2014 -

The George Washington UniversityDepartment of Health ServicesManagement and Leadership2021 K Street NW, Suite 800Washington, DC 20006202-994-4100 · fax 202-994-4040

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Table of Contents

Methodology and Findings………………...………………………………………………………………………………………………………….2

CPT/HCPCS-II Codes………………….……………………………………………………………………………………………………………..4

Maps of State Coverage…………………….…………………………………………………………………………………………………………5

State-by-State Charts (sorted alphabetically)…..….…………………………………………………………………………………………………11

Appendix: Standard EPSDT Coverage……………………………………………………………………………………………………………….63

Sources……………………………………………………………………………………………………………………………………………..…64

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Methodology and Findings

Methodology:Research findings are based on an online document review of Medicaid provider manuals, drug formularies, and fee schedules conducted between September and November 2014.Findings are categorized into three broad categories: Nutritional Assessment/Consultation, Pharmaceutical Therapy, and Bariatric Surgery. We grouped CPT codes into four sub-categories: preventive counseling, nutritional consultation, disease management and education, and behavioral consultation and therapy. For the EPSDT sub-section, only servicesin excess of standard EPSDT coverage (refer to the Appendix for CMS regulations concerning EPSDT) are reported.

Search terms included: obesity, morbid obesity, weight, weight-loss, diet, nutrition, bariatric surgery, gastric bypass, roux-en-y, anorexiant, appetite suppressant, Phentermine,Adipex, Suprenza, Lonamin, Orlistat, Xenical. Qsymia, Belviq, and Lorcaserin

Findings:Prevention-Eight states and the District of Columbia cover all obesity-related preventive care CPT codes. 19 states cover one or more obesity-related preventive care CPT code. 21 statescover no obesity-related preventive care CPT codes and/or state that obesity-related preventive care services are explicitly excluded in respective provider manuals. Coverage forone state (KS) was undeterminable. Coverage for TN was not assessed as the state’s Medicaid population is entirely managed care.

Nutrition-15 states and the District of Columbia cover all obesity-related nutritional consult CPT codes. 13 states cover one or more obesity-related nutritional consult CPT code. 20 statescover no obesity-related nutritional consult CPT codes. Coverage for one state – KS – was undeterminable. Coverage for TN was not assessed as the state’s Medicaid population isentirely managed care.

Provider manuals indicated that while six states – CT, MN, NM, SD, UT, WV – may utilize nutrition CPT codes, they are not reimbursable for treating obesity. Provider manualsalso indicated that four states – GA, MI, NE, VT – that do not utilize nutrition CPT codes, do reimburse for nutritional counseling.

Disease Management-One state cover all obesity-related disease management CPT codes. 18 states and the District of Columbia cover one or more obesity-related disease management CPT codes. 29states cover no obesity-related disease management CPT codes. Coverage for one state – KS – was undeterminable. Coverage for TN was not assessed as the state’s Medicaidpopulation is entirely managed care.

Behavioral Consultation-12 states and the District of Columbia cover all obesity-related behavioral consult CPT codes. 17 states cover one or more obesity-related behavioral consult CPT code. 19 statescover no obesity-related behavioral consult CPT codes. Coverage for one state – KS – was undeterminable. Coverage for TN was not assessed as the state’s Medicaid population isentirely managed care.

Pharmaceuticals-Fourteen states cover obesity drugs. Of these states, five – AL, LA, ND, NJ, SC – limit coverage to lipase inhibitors (Orlistat/Xenical). Five states – Alabama, Hawaii, NorthDakota, Virginia, and Wisconsin – require that certain weight-loss benchmarks be met over a specified timeframe in order to continue medication coverage oncestarted.36 states explicitly exclude all obesity drug coverage, with one state – VT – expressly citing safety concerns as justification for non-coverage. Coverage for 1 state – KS –was undeterminable.

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Xenical: seven states – Alabama, Hawaii, Idaho, Michigan, North Dakota, Virginia, and Wisconsin - cover Xenical with a prior authorization. Four states – Arkansas,Connecticut, Louisiana, and New Hampshire - do not have Xenical listed on the preferred drug list (PDL) or prior authorization list, but claim drugs not on the PDL willbe covered with documented medical necessity and prior authorization. One state – Maryland – does not cover Xenical.

Alli: Five states – Arkansas, Connecticut, Hawaii, Louisiana, New Hampshire - did not have Alli on the PDL or prior authorization list but claim drugs not on the PDLwill be covered with documented medical necessity and prior authorization. 4 states – Alabama, Maryland, Michigan, North Dakota - do not cover Alli. 3 states – Idaho,Vriginia, and Wisconsin - had indeterminable coverage.

Qsymia: One state – Wisconsin - covers Qsymia with a prior authorization. 6 states – Arkansas, Connecticut, Hawaii, Idaho, Louisiana, and New Hampshire – did nothave Qsymia on the PDL or prior authorization list but claim drugs not on the PDL will be covered with documented medical necessity and prior authorization. 4 states –Alabama, Maryland, Michigan, and North Dakota – do not cover Qsymia. 1 state – Virginia - had indeterminable coverage.

Belviq: Two states – Maryland and Wisconsin – cover Belviq with a prior authorization. 7 states – Arkansas, Connecticut, Hawaii, Idaho, Louisiana, Michigan, and NewHampshire - did not have Belviq on the PDL or prior authorization list but claim drugs not on the PDL will be covered with documented medical necessity and priorauthorization. 2 states – Alabama and North Dakota – do not cover Belviq. 1 state – Virginia – had indeterminable coverage.

Phentermine: Forty-one states do not cover phentermine. Of the remaining 10 states, 9 states – ID, AR, HI, VA, RI, NH, FL, MD – did not have Phentermine on the PDLor prior authorization list but claim drugs not on the PDL will be covered with documented medical necessity and prior authorization. One state – KS – hadundeterminable coverage. WI is the only state to clearly cover phentermine.

Bariatric Surgery-47 states and the District of Columbia cover bariatric surgery. Of these states, 36 require prior authorization and 37 require criteria other than BMI alone to determine eligibility.Three states (MT, MS, OH) explicitly exclude bariatric surgery.

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CPT/HCPCS-II code Code description Obesity-related service

Prevention99401-99404 or 99411-

99412Counseling and/or risk factor reduction intervention (individual or group) Obesity prevention counseling

Nutrition

S9452 Nutrition class, non-physician provider Nutrition class

97802-97804 and/or S9470Medical nutrition therapy (individual or group); nutritional assessment

and intervention by non-physician providerNutritional counseling

Disease Management

99078Miscellaneous services; physician educational services to patients in

group setting

Group counseling for patients with

symptoms/illnesses

S0315-S0316Health education disease management program; initial and follow-up

assessmentsHealth education

S9445-S9446Patient education, not otherwise specified non-physician provider,

individual or groupHealth education

98960-98962 Education and training for patient self-management, by non-physicianCounseling for individuals or groups of patients

with symptoms/illnesses

Behavioral Consult and Therapy

96150-96155

Health and behavior assessments (health-focused clinical interview,

behavior observations, psychophysiological monitoring, health-oriented

questionnaires)

Health and behavioral intervention/counseling

S9449 Weight management class, non-physician provider Weight management class

S9451 Exercise class, non-physician provider, per session Exercise class

CPT/HCPCS-II Codes

In the State-by-State Charts section, if CPT/HCPCS-II codes are listed for a state, refer to the table below for a full listing of which codes match which services. States may stillrestrict eligibility for these benefits and may summarily exclude their use for the prevention and treatment of obesity, however, we did not find an indication in the providermanuals or fee schedules to indicate that this is the case.

Providers and beneficiaries should always check with their respective billing entity before assuming services are covered.

Table 1: Obesity-related CPT/HCPCS-II Codes

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Maps of State Coverage

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ALABAMAAlabama Medicaid Agency

Nutritional Assessment/Counseling1,2 Pharmaceutical Therapy3 Bariatric Surgery4

Adults:Medicaid does not cover dietitians except for recipientsunder 21 years of age.

CPT Codes: 99401-99402

EPSDT:Diet instruction performed by a physician is consideredpart of a routine visit

EPSTD screenings will be covered only if the provideris enrolled in that program. Screenings are not subjectedto prior authorization.

Prior authorization required. PA requirements notspecified beyond PA form.

Xenical is the only agent currently covered.

To receive prior authorization for Xenical®, the patientmust be 18 years of age or older and have at least one ofthe following primary medical diagnoses: Diabetes mellitus Hypertension Hyperlipidemia

Renewal requests require the patient’s previous andcurrent weights (in pounds). Continued weight loss mustbe documented for renewals.

There must be documentation in the patient record tosupport failure with prior physician supervisedexercise/diet regimen(s) of at least 6 months duration.Documentation must also show that adjuvant therapy isplanned.

Medical justification may include peer-reviewedliterature, medical record documentation, or otherinformation specifically requested.

Approval may be given for up to 3 months with initialrequest, and up to 6 months for each subsequent requestto a total approval period not to exceed 2 years for therecipient.

Prior authorization required.

Must be within 18 and 64 years of age. Must meetspecific medical criteria and PA or the surgery will beconsidered cosmetic and will not be covered byMedicaid.

Specific prior authorization criteria not found.

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ALASKADepartment of Health and Social Services

Nutritional Assessment/Counseling5,6,7 Pharmaceutical Therapy8 Bariatric Surgery9

Adults:Swimming therapy, weight loss programs,programs to improve overall fitness, andmaintenance therapy are not covered services.

CPT Codes: 99401-99404

EPSDT:Obesity services outside of mandated EPSDT services arenot explicitly mentioned.

Coverage for a child under 21 years of age includes oneinitial assessment within a calendar year, and up to 12additional hours within a calendar year for counselingand follow-up care, unless additional visits are prescribedby a physician, ANP, or other licensed healthcarepractitioner who may order those services within thescope of the practitioner’s license. If additional visits areneeded, Provider must obtain service authorization.

Services related to weight loss or obesity are not covered. Prior authorization required.

Gastric bypass may be covered if there is medicaljustification and if a service authorization is received.


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ARIZONAHealth Care Cost Containment System (AHCCCS)

Nutritional Assessment/Counseling10 Pharmaceutical Therapy11 Bariatric Surgery12

Adults: Not explicitly mentioned.

CPT Codes: 96150-96155, 99401-99404, 99411-99412,97802-97804, S9470, S0315-S0316, S9452

EPSDT:Nutritional assessments are conducted to assist EPSDTmembers whose health status may improve withnutrition intervention. AHCCCS covers the assessmentof nutritional status provided by the member's primarycare provider (PCP) as a part of the EPSDT screeningsspecified in the AHCCCS EPSDT Periodicity Schedule,and on an inter-periodic basis as determined necessaryby the member’s PCP. AHCCCS also covers nutritionalassessments provided by a registered dietitian whenordered by the member's PCP. This includes EPSDTeligible members who are under or overweight.To initiate the referral for a nutritional assessment, thePCP must use the Contractor referral form in accordancewith Contractor protocols. Prior authorization (PA) isnot required when the assessment is ordered by the PCP.

Includes note in the periodicity schedule that, “IfAmerican Academy of Pediatrics guidelines are used forthe screening schedule and/or more screenings aremedically necessary, those additional interperiodicscreenings will be covered.”

Excluded drugs include: Anti obesity agents


Bariatric surgery will continue to be covered underMedicaid, AHCCCS providers must use evidence-basedguidelines before authorizing bariatric surgery.

Specific prior authorization and evidence-based guidelinecriteria not found.

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ARKANSASArkansas Medicaid

Nutritional Assessment/Counseling Pharmaceutical Therapy13 Bariatric Surgery14

Adults: Not explicitly mentioned

CPT Codes: 99401-99402

EPSDT:Obesity services outside of mandated EPSDT services are notexplicitly mentioned.

No information available Prior authorization required

A. The patient must be between 18 and 65 years of age.B. The beneficiary has a documented body-mass index >35 and

has at least one co-morbidity related to obesity.C. The beneficiary must be free of endocrine disease as supported

by an endocrine study consisting of a T3, T4, blood sugar and a17-Keto Steroid or Plasma Cortisol.

D. Under the supervision of a physician the beneficiary has madeat least one documented attempt to lose weight in the past. Themedically supervised weight loss attempt(s) as defined abovemust have been at least six months in duration.

E. Medical and psychiatric contraindications to the surgicalprocedure have been ruled out (and referrals made as necessary)

F. A complete history and physical, documenting1. beneficiary’s height, weight, and BMI2. the exclusion or diagnosis of genetic or syndromic

obesity, such as Prader-Willi Syndrome,G. A psychiatric evaluation no more than three months prior to the

requesting authorization. The evaluation should address theseissues:

1. Ability to provide, without coercion, informedconsent,

2. family and social support,3. patient ability to comply with the postoperative care

plan and, identify potential psychiatriccontraindications

Covered Procedures Open and laparoscopic Roux-en-Y gastric bypass (RYGBP) Open and laparoscopic Biliopancreatic Diversion with

Duodenal Switch (BPD/DS) Laparoscopic adjustable gastric banding (LAGB) Vertical

banded gastroplasty Gastric Bypass

Non-covered Procedures The following bariatric surgery procedures are non-covered: Open adjustable gastric banding Open and laparoscopic sleeve gastrectomy

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CALIFORNIAMedi-Cal

Nutritional Assessment/Counseling Pharmaceutical Therapy Bariatric Surgery15


CPT Codes: 96150-96153, 99401, S9470


Excluded (not included in drug formulary or mentionedin provider manual).

Prior authorization required

Morbid obesity can be a health danger because of the associatedincreased prevalence of cardiovascular risk factors such ashypertension, hypertriglyceridemia, hyperinsulinemia, diabetes mellitusand low levels of high-density lipoprotein (HDL) cholesterol.Conservative and dietary treatments include low (800 – 1200) calorieand very low (400 – 800) calorie diets, behavioral modification,exercise and pharmacologic agents. When these less drastic measureshave failed or are not appropriate, providers may use the followingsurgical treatment options for morbidly obese recipients. TAR approvalis required and recipients must meet ALL criteria specified:

The recipient has a BMI, the ratio of weight (in kilograms) tothe square of height (in meters), of: Greater than 40, or Greaterthan 35 if substantial co-morbidity exists, such as life-threatening cardiovascular or pulmonary disease, sleep apnea,uncontrolled diabetes mellitus, or severe neurological ormusculoskeletal problems likely to be alleviated by the surgery.

The recipient has failed to sustain weight loss on conservative regimens. Examples of appropriate documentation of failure of

conservative regimens include but are not limited to:o Severe obesity has persisted for at least five years despite a

structured physician-supervised weight-loss program withor without an exercise program for a minimum of sixmonths.

o Serial-charted documentation that a two-year managedweight-loss program including dietary control has beenineffective in achieving a medically significant weight loss.

The recipient has a clear understanding of available alternativesand how his or her life will be changed after surgery, includingthe possibility of morbidity and even mortality, and a crediblecommitment to make the life changes necessary to maintain thebody size and health achieved.

The recipient has received a pre-operative medical consultationand is an acceptable surgical candidate

Authorization for bariatric surgery will only be approved for aCenters for Medicare and Medicaid Services certified Center ofExcellence

Additional criteria apply - refer to source for full criteria

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COLORADODepartment of Health Care Policy and Finance

NutritionalAssessment/Counseling16

Pharmaceutical Therapy17 Bariatric Surgery18


CPT Codes: 96150-96155, 99401-99404, 99411-99412, S9445

EPSDT:Obesity services outside of mandatedEPSDT services are not explicitlymentioned.

Excluded drugs include: Drugs for anorexia (weight loss)

Colorado Medicaid covers bariatric surgery for enrolledMedicaid clients over the age of 16 when the client has clinicalobesity and it is medically necessary. Clients must have a BMIod 40 or higher. BMI of 35-40 must document one or more ofthe listed co-morbid conditions.

Covered procedures include: Roux-en-Y Gastric Bypass;Adjustable Gastric Banding; Biliopancreatic Diversion with orwithout Duodenal Switch; Vertical-Banded Gastroplasty;Vertical Sleeve Gastroplasty

All bariatric surgical procedures require prior authorization.Refer the source for more information.

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CONNECTICUTDepartment of Social Services


Adults:The Department will not cover services to treat obesityother than those described in section 17b-262-341(9) ofthe Regulations of Connecticut State Agencies whichstates that the Agency shall pay for surgical servicesnecessary to treat morbid obesity [when] as defined bythe ICD that causes or aggravates another medicalillness [is caused by, or is aggravated by, the obesity.Such illnesses shall include, including illnesses of theendocrine system or the cardio-pulmonary system, orphysical trauma associated with the orthopedic system.For the purposes of this section, “morbid obesity” means“morbid obesity” as defined by the InternationalClassification of Diseases (ICD), as amended from timeto time]

CPT Codes: 99401-99404, 99411-99412

EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned.

Excluded drugs include: Any drugs used in the treatment of obesity.

Covered when medically necessary as defined by the ICDthat causes or aggravates another medical illness,including illnesses of the endocrine system or the cardio-pulmonary system, or physical trauma associated with theorthopedic system.

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DELAWAREHealth & Social Services Division of Medicaid & Medical Assistance



CPT Codes: 96150-96154, S9470,


Drugs indicated for the treatment of obesity are notroutinely covered by the DMAP.


The DMAP may cover bariatric surgery for treatment ofobesity in adults when the patient’s obesity is causingsignificant illness and incapacitation and when allother more conservative treatment options have failed.

All requests for bariatric surgery must be priorauthorized. This includes the surgeon, assistant surgeon(if medically necessary), anesthesiologist, and facility.

Requests for prior authorizations of bariatric surgerymust be submitted in writing.


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DISTRICT OF COLUMBIADepartment of Health Care Finance



CPT Codes: 96151-96155, 99401 - 99404, 99411,S9470, S9445, S9452, 97802-97804


Excluded drugs include: Anti-obesity drugs


Gastric bypass requires written justification and priorauthorization.

Specific prior authorization criteria not defined.

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FLORIDAAgency for Health Care Administration



CPT Codes: 99401-99403

EPSDT:Based on the provider’s medical discretion, thefollowing elements, as appropriate for the child’s ageand health history, should be documented: Height and weight (measure and plot on a standard

chart)

Includes note to: See the CDC website atwww.cdc.gov/growthcharts/;AAP website atwww.aap.org; and Bright Futures website atwww.brightfutures.org for information on new growthcharts to calculate and plot weight, height, and BodyMass Index (BMI) using age and gender-appropriategraphs; as well as, information on weight problems, suchas obesity.

Anticipatory guidance follows AAP BrightFuturesAnticipatory Guidelines

Medicaid does not reimburse for appetite suppressants(unless prescribed for an indication other than obesity)


All bariatric surgical procedures require priorauthorization by the inpatient hospital Medicaid QIO peerreview organization.

All bariatric surgical procedures requested for overweightand obesity must use the additional ICD-9 code toidentify body mass index (V85.1-V85.45).

Note: See Authorization for Inpatient Hospital Admissionin Chapter 2 in the Florida Medicaid ProviderReimbursement Handbook, CMS-1500, for the inpatienthospitalization authorization procedures. The FloridaMedicaid Handbooks are located on the fiscal agent’swebsite at www.my-medicaid-florida.com


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GEORGIADepartment of Community Health


Adults:The Diagnostic, Screening and Preventive ServicesProgram reimburses a broad range of diagnostic,screening, and preventive services. These services areprovided at an office, clinic, school-based clinic, orsimilar facility in Georgia. Services include nutritionalcounseling.

Nutritional Counseling (Individual & Group): Dietitianslicensed by the Georgia Board of Examiners may bill forNutritional Counseling. Medicaid reimburses for newpatient nutritional assessment, established patientnutritional, counseling and nutritional group counselingvisits:

Nutritional Counseling (individual or group) can bebilled as a single service if it was the only serviceprovided that day.

Nutritional Counseling (individual or group) rendered incombination with other clinic services on a particular dayshould not be billed separately.

Nutritional Counseling for WIC-eligible members mustbe beyond the first two (2) nutrition education contacts.

Nutritional Group Counseling classes must be specific toclient’s nutrition-related medical condition anddiagnosis.

CPT Codes: None

EPSDT:Obesity services outside of mandated EPSDT services are notexplicitly mentioned.

Excluded drugs include: Agents used for anorexia, weight gain or weight loss.

Bariatric Surgery for the treatment of morbid obesity is consideredmedically necessary when the following criteria are met:1. Presence of morbid obesity; and2. Member has completed growth (18 years of age or documentationof completion of bone growth); and3. The member must concurrently participate in an organizedmultidisciplinary surgical preparatory regimen coordinated by aqualified bariatric surgeon in order to improve surgical outcomes,reduce the potential for surgical complications, and establish themember's ability to comply with post-operative medical care anddietary restrictions; and4. Member has participated in a physician-supervised nutrition andexercise program (including a low calorie diet, increased physicalactivity, and behavioral modification); and5. Mental health evaluation by a psychiatrist or psychologist todetermine any contraindications as listed below, mental competencyand understanding of the nature, extent and possible complicationsof the surgery and ability to sustain dietary behavioral modificationsneeded to ensure a successful outcome of surgery.

Procedures CoveredOnly the following surgical procedures are covered:a. Gastric segmentation along its vertical axis with a Roux-en Ybypass with distal anastomosis placed in the jejunum (Open - CPT43846 or 43847 and Laparoscopic -CPT 43644)b. Laparoscopic adjustable silicone gastric banding (LASGB) (CPT43770)c. Biliopancreatic Diversion with Duodenal Switch (Open -CPT43847)

Non-Covered ProceduresThe following procedures are not covered due to being unsafe or notadequately studied:a. Open adjustable gastric banding (CPT 43843)b. Open and laparoscopic vertical banded gastroplasty (CPT 43842)c. Gastric balloon (CPT 43843)d. Intestinal bypass (CPT43659 )

Additional criteria apply – refer to source for full criteria

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HAWAIIMed-QUEST



CPT Codes: 96150-96155

EPSDT:The screenings, assessments, surveillance, andanticipatory guidance under EPSDT are based upon therecommendations of CMS and the most currentAmerican Academy of Pediatrics (AAP) and BrightFutures guidelines.

Other services are covered under EPSDT for clients upto the age of 21 years when the client’s physician hascompleted and submitted a prior authorization and DHShas determined that the services are medicallynecessary.

Prior authorization required for appetite suppressants(anorexics) and medications for weight loss

General Prior Authorization Requirements:1. Must be for one of the indications noted above; and2. Used in conjunction with a reduced calorie diet

Xenical/Orlistat Prior Authorization Requirements:1. Patient’s height and weight or BMI;2. Patient’s program for weight loss.

Indications:1. For patients with an initial Body Mass Index (BMI)greater than or equal to 30kg/m2 OR greater than or equalto 27kg/m2 in the presence of at least one other riskfactor such as hypertension, sleep apnea, diabetes,dyslipidemia, coronary heart disease or otherartherosclerotic diseases; and2. Maintenance of weight loss

Other types of weight loss products such asMeridia/Sibutramine may have more specific priorauthorization criteria

Initial approval will be for a maximum of 3 months. Ifthere is weight loss or the recipient has been able tomaintain prior weight loss during this initial period,subsequent prior authorization requests may be approvedup to a maximum of 6 months.

Refer to source for full criteria.


Prior authorizations required for gastroplasty for morbidobesity.

Prior authorization criteria not detailed.

Jejuno-ileal bypass procedures for morbid obesity isspecifically excluded.

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IDAHODepartment of Health and Welfare

Nutritional Assessment/Counseling37 Pharmaceutical Therapy38 Bariatric Surgery39,40


CPT Codes: 99401-99404, S9470

EPSDT:Following criteria must be met for dietary counseling Ordered by a physician Determined to be medically necessary Payment for two visits during the calendar year

is available at a rate established by DHW

Children may receive two additional visits whenprior authorized.


Must meet all criteria before coverage will be considered BMI > 40 with no co-morbidity or BMI > 35 with co-

morbidity Waist-to-Hip ratio 0.8-0.85 in females or 0.95-1.0 in

males Failed diet and exercise alone (include chart notes

showing trials and failures) Age over 18 years


Medicaid will only cover bariatric surgeries, includingabdominoplasty and panniculectomy,when all of the following conditions are met:

The participant meets the criteria for morbid obesity asdefined in IDAPA 16.03.09.431Surgical Procedures forWeight Loss Participant Eligibility through 434 SurgicalProcedures for Weight Loss Provider Qualifications andDuties online athttp://adminrules.idaho.gov/rules/current/16/0309.pdf

The procedure is prior authorized by Qualis Health. Ifapproval is granted, Qualis Health will issue theauthorization number and conduct a length – of- stayreview

The procedure(s) must be performed in an approvedbariatric surgery center (BSC)or bariatric surgery center of excellence (BSCE). A list offacilities for bariatric surgery is available online from theSurgical Review Corporation

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ILLINOISDepartment of Healthcare and Family Services



CPT Codes: 97802- 97804, 96150 - 96155

EPSDT:Obesity services are mentioned but not explicitlydetailed; focuses entirely on preventive action

Excluded drugs include: Weight loss drugs


Effective with dates of service October 1, 2012, and after,providers will be required to request prior approval forsurgeries for morbid obesity.

Payment for this service may be made only in those casesin which the physician determines that obesity isexogenous in nature, the recipient has had the benefit ofother therapy with no success, endocrine disorders havebeen ruled out, and the body mass index (BMI) is 40 orhigher, or 35 to 39.9 with serious medical complications.

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INDIANAOffice of Medicaid Policy and Planning

Nutritional Assessment/Counseling Pharmaceutical Therapy44 Bariatric Surgery45,46


CPT Codes: 96150-96155, 99401, 99403-99404,99411-99412, 97802-97804, 99078, S0315- S0316,S9445-S9446, S9449, S9451-S9452, S9470, 98960-98962


Excluded drugs include: Anorectics or any agent used to promote weight

loss


Bariatric surgery is recognized as medically necessarywhen used for the treatment of morbid obesity. As ofJune 1st 2014, Sleeve gastrectomy will be covered. Alltypes of bariatric surgery are subject to the followingconditions.

Scope and duration of failed weight loss therapy mustmeet the following criteria.

a. Morbid obesity has persisted for at least fiveyears duration, and b. Physician-supervised non-surgical medical treatment 2 has beenunsuccessful for at least 6 consecutive months.Or

b. Member has successfully achieved weight lossafter participating in physician-supervised non-surgical medical treatment but has beenunsuccessful at maintaining weight loss for twoyears [ > 3 kg (6.6 lb.) weight gain].

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IOWADepartment of Human Services



CPT Codes: 96150- 96151, 99402, 97802-97804,S9470, 98960-98962

EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned however, Licenseddietitians employed by or under contract with physiciansmay provide nutritional counseling services to recipientsage 20 and under.

Excluded drugs include: Drugs used to cause anorexia, weight gain or

weight loss


Specific prior approval criteria not found.

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KANSASKansas Health Policy Authority

Nutritional Assessment/Counseling Pharmaceutical Therapy Bariatric Surgery50,51

Adults:Provider Manual was inaccessible with weblink on stateMedicaid agencies website

CPT Codes: MediKan (Traditional FFS Medicaid): None

EPSDT:Provider Manual was inaccessible with weblink on stateMedicaid agencies website

None found. Prior authorization required.

Open or laparoscopic Roux-en-Y bypass (RYGB), openor laparoscopic biliopancreatic diversion (BPD), with orwithout duodenal switch (DS), or laparoscopic adjustablesilicone gastric banding (LASGB) will be consideredmedically necessary when selection criteria are met.

Must meet either 1 (adults) or 2 (adolescents):

1. For adults aged 18 years or older, presence of severeobesity that has persisted for at least the last 2 years (24months), documented in contemporaneous clinicalrecords, defined as any one of the following: Body mass index (BMI) exceeding 40 BMI greater than 35 in conjunction with either of

the following severe comorbidities:o Clinically significant obstructive sleep apneao Coronary heart diseaseo Medically refractory hypertension (blood

pressure greater than 140 mmHg systolicand/or 90 mmHg diastolic despite concurrentuse of 3 anti-hypertensive agents of differentclasses)

o Type 2 diabetes mellitus2. Consumer has attempted weight loss in past without

successful long-term weight reduction ANDConsumer must meet either physician-supervisednutrition and exercise program or multi-disciplinarysurgical preparatory regimen)

Bariatric surgery is only covered when performed at aCenter of Excellence.

Additional criteria apply – including separate criteria forchildren and adolescents - refer to source for full criteria

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KENTUCKYDepartment for Medicaid Services

Cabinet for Health and Family Services

NutritionalAssessment/Counseling

Pharmceutical Therapy52 Bariatric Surgery53


CPT Codes: 96150-96153, 97802-97804

EPSDT:Obesity services outside of mandatedEPSDT services are not explicitlymentioned.

Excluded drugs include: Drugs used for anorexia, weight loss, or weight gain

Prior authorization required.Bariatric Surgery for the treatment of morbidobesity is considered medically necessary whenpre-authorized with the following criteria met.

Refer to source for full criteria

29

LOUISIANAMedicaid (Health Services Financing)

Office of Management and Finance, Department of Health and Hospitals



CPT Codes: 96150-96155, 97802-97804


Excluded drugs include: Anorexics – Medicaid does not reimburse for

anorexics with the exception of orlistat;

Medicaid will provide reimbursement to outpatientpharmacies for orlistat prescriptions based on thefollowing 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 theprescriber had identified the BMI, in his/herhandwriting, on the dated prescription or a dated andsigned attachment to the prescription;

Patient has other risk factors warranting the use ofOrlistat and the prescriber has identified an approvedICD-9-CM diagnosis code in his/her handwriting, onthe dated prescription or a dated and signedattachment to the prescription; and

No provisions for override of the prospective drugutilization edits, i.e., early refill (ER) and duplicatedrug (ID) editing.


Requires prior authorization.

Louisiana Medicaid covers bariatric or weight losssurgery as an option only after a comprehensive andsustained program of diet and exercise with or withoutpharmacologic measures has been unsuccessful overtime. Bariatric surgery may consist of open orlaparoscopic procedures that revise the gastro-intestinalanatomy to restrict the size of the stomach and/or reduceabsorption of nutrients.

Prior Authorization: Surgeons who perform bariatricsurgery must obtain prior authorization through the fiscalintermediary’s Prior Authorization (PA) Unit. The PArequest shall include a thorough multidisciplinaryevaluation within the previous 12 months.

NOTE: A physician letter documenting recipientqualifications and medical necessity must accompany thePA request and must include confirmatory evidence ofco-morbid condition(s). Photographs must besubmitted with the request for consideration ofbariatric surgery.

30

MAINEOffice of MaineCare Services

Department of Health and Human Services



CPT Codes: 99401-99403, 99411-99412,97802-97803, 96150- 96154

EPSDT:Obesity services outside of mandated EPSDTservices are not explicitly mentioned.

Excluded drugs include: Anorexic, or certain weight loss drugs.

Requires prior authorization.

Reimbursement will be made to thephysician, hospital or other health careprovider for services related to gastricbypass, gastroplasty surgery or adjustablegastric banding only when prior approvalhas been granted by the Department . Therequest for prior authorization must besubmitted by the surgeon who will beperforming the surgery.

For Members age twenty-one (21) yearsand younger, the surgery must also berecommended by all of thefollowing, with documentation submittedwith the prior approval request. Please seesource for full criteria.

31

MARYLANDMedical Programs, Department of Health and Mental Hygiene



CPT Codes: HealthChoice is a series of managed careplans with individual fee schedules (individuals shouldcontact their respective MCO provider for coveragedetails).

EPSDT:Initial screening services include the full scope ofcomprehensive services outlined in the MarylandEPSDT Preventive Health Schedule. See source formore details. Obesity services outside of mandatedEPSDT services are not explicitly mentioned.

.

Prior authorization required: Belviq (Lorcaserin)

Not covered: Xenical/Alli (Orlistat)


PA criteria not found.

32

MASSACHUSETTSMassHealth, Office of Health and Human Services


Adults: Does not explicitly mention.

CPT Codes: None


The MassHealth agency does not pay for any drug usedfor the treatment of obesity.


MassHealth reviews requests for prior authorization onthe basis of medical necessity. If MassHealth approvesthe request, payment is still subject to all generalconditions of MassHealth, including member eligibility,other insurance, and program restrictions.

MassHealth bases its determination of medical necessityfor bariatric surgery on a combination of clinical data andpresence of indicators that would affect the relative risksand benefits of the procedure (if appropriate, includingpost-operative recovery).

Specific prior authorization criteria not found

33

MICHIGANDepartment of Community Health

Nutritional Assessment/Counseling63 Pharmaceutical Therapy64,65 Bariatric Surgery66

Adults:MDCH policy covers obesity treatment when done forthe purpose of controlling life-endangeringcomplications such as hypertension and diabetes. Thisdoes not include treatment specifically for obesity,weight reduction and maintenance alone. The physicianmust request PA and document that other weightreduction efforts and/or additional treatment ofconservative measures to control weight and manage thecomplications have failed.

The request for PA must include: The medical history; Past and current treatment and results; Complications encountered; All weight control methods that have been tried and

failed; and Expected benefits or prognosis for the method being

requested.

CPT Codes: None

EPSDT:Well-Child visits follow the American Academy ofPediatrics Recommendations for Preventive PediatricHealth Care which indicates all components and age-specific indicators for performing the variouscomponents.

Treatment guidelines not found.

MDCH policy covers obesity treatment when done forthe purpose of controlling life-endangering complicationssuch as hypertension and diabetes. This does not includetreatment specifically for obesity, weight reduction andmaintenance alone. The physician must request PA anddocument that other weight reduction efforts and/oradditional treatment of conservative measures to controlweight and manage the complications have failed.

The request for PA must include: The medical history; Past and current treatment and results; Complications encountered; All weight control methods that have been tried and

failed; and Expected benefits or prognosis for the method being

requested.

Prior Authorization form only available forXenical/Orlistat


MDCH policy covers obesity treatment when done forthe purpose of controlling life-endangering complicationssuch as hypertension and diabetes. This does not includetreatment specifically for obesity, weight reduction andmaintenance alone. The physician must request PA anddocument that other weight reduction efforts and/oradditional treatment of conservative measures to controlweight and manage the complications have failed.The request for PA must include:

The medical history; Past and current treatment and results; Complications encountered; All weight control methods that have been tried

and failed; and Expected benefits or prognosis for the method

being requested.

If surgical intervention is desired, a psychiatricevaluation of the beneficiary’s willingness/ability to altertheir lifestyle following surgical intervention must beincluded.

If the request is approved, the provider receives anauthorization letter for the service, including billinginstructions. A copy of the authorization letter must beattached to all claims submitted to MDCH forweight reduction services

34

MINNESOTADepartment of Human Services


Adults:MHCP covers physician visits, medical nutritionaltherapy, mental health services*, and laboratory workprovided for weight management. Services must bebilled by enrolled providers on a component basis withcurrent CPT codes.

If an MHCP recipient elects to participate in a weightloss program, the recipient may be billed forcomponents of the program that are not covered, as longas the recipient is informed of charges in advance.

CPT Codes: 96150-96154, 99401-99404, 99411-99412,97802-97804, S9470, 98960-98962, 99078, S0315-S0316


Adolescent bariatric surgery coverage detailed at samelink as adult

Excluded drugs include: Drugs which are limited or excluded by the

state as allowed by federal law (OBRA 90)


All of the criteria listed below must be met in order to authorizebariatric surgery. Patients not meeting the criteria, who have oneor more immediate, life-threatening comorbidities, will beconsidered for approval on a case-by-case basis:

1. The recipient is clinically obese with one of the follow: BMI of 40 or higher BMI of 35-40 with one or more comorbid

conditions.2. The BMI level qualifying the patient for surgery (> 40 or >

35 with one of the above comorbidities) must be of at leasttwo years duration. A patient’s required attempt(s) to lose weight may

cause their BMI to fluctuate around the discreterequired levels during the two-year period. The two-year period will not necessarily start over, or beprolonged, under this scenario, but will be decided on acase-by-case basis.

The recipient has made at least one serious medicallysupervised attempt to lose weight in the past, under thesupervision of a physician, physician’s assistant, nursepractitioner, or registered dietician. The medicallysupervised weight loss attempt(s) must have been atleast six months in duration

3. Medical and psychiatric contraindications to the surgicalprocedure have been ruled out


35

MISSISSIPPIDivision of Medicaid



CPT Codes: None.

EPSDT:Primary care providers or other health centers thatprovide primary care services must offer to conductperiodic and medically necessary interperiodic visits toscreen all Medicaid-eligible children and youth up toage twenty-one (21) in accordance with the EPSDTPeriodicity Schedule as recommended by the AmericanAcademy of Pediatrics, and must provide or refer suchbeneficiaries to assessment, diagnosis, and treatmentservices.

Treatment guidelines not found.

Pharmacy program exclusions include: Drugs 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 weightcontrol, regardless of medical necessity.

36

MISSOURIMO HealthNet Division, Department of Social Services


Adults:The treatment of obesity is noncovered unless thetreatment is an integral and necessary part of a course oftreatment for a concurrent or complicating medicalcondition.

CPT Codes: 99402, 99404, S0315-S0316


Drugs used to promote weight loss are excluded underMO HealthNet.

Morbid obesity treatment:Morbid obesity, as defined by the American MedicalAssociation (AMA) is a Body Mass Index (BMI) greaterthan 40. The treatment of obesity is covered by MOHealthNet (MHD) when the treatment is an integral andnecessary course of treatment for a concurrent orcomplicating medical treatment. The following codes forbariatric surgery, gastric bypass, gastroplasty, andlaparoscopy are covered codes by MHD for patients witha BMI of greater than 40 and a co-morbid condition(s).These services must be prior authorized. Refer to section8 of the physician's manual to review MHD's priorauthorization policy.43644 43645 43659 43770 43845 43846 43847 43848

The following are covered codes by MHD for patientswith a BMI of greater than 40 and a co-morbidcondition(s), but do not require a prior authorizationrequest.43771 43772 43773 43774

37

MONTANADepartment of Public Health and Human Services


Adults:Physicians and mid-level practitioners who counseland monitor clients on weight reduction programscan be paid for those services. If medical necessityis documented, Medicaid will also cover lab work.Similar services provided by nutritionists are notcovered for adults.• Medicaid does not cover the following weightreduction services:• Weight reduction plans/programs (e.g., JennyCraig, Weight Watchers)• Nutritional supplements• Dietary supplements• Health club memberships• Educational services of nutritionists

CPT Codes: 96150, 99401-99404, 99411-99412,97802-97804


The Medicaid prescription drug programdoes not reimburse for the followingitems or services: drugs prescribed for weight reduction

Gastric Bypass Surgery and weight loss surgery foradults are not covered under basic Montana Medicaid.

Covered by Full Medicaid for individuals under 21years old.(http://medicaidprovider.hhs.mt.gov/pdf/medicaidinfohandbook.pdf)

38

NEBRASKADepartment of Health & Human Services


Adults:Treatment for obesity:NMAP will not make payment for services providedwhen the sole diagnosis is "obesity". Obesity itselfcannot be considered an illness. The immediate cause isa caloric intake which is persistently higher than caloricoutput. When obesity is the only diagnosis, treatmentcannot be considered reasonable and necessary for thediagnosis or treatment of an illness or injury.

While obesity is not itself considered an illness, there areconditions which can be caused by or aggravated byobesity. This may include, but is not limited to thefollowing: hypothyroidism, Cushing's disease,hypothalamic lesions, cardiac diseases, respiratorydiseases, diabetes, hypertension, and diseases of theskeletal system. Treatment for obesity may be coveredwhen the services are an integral and necessary part of acourse of treatment for another serious medicalcondition.

CPT Codes: None

EPSDT:Obesity is considered appropriate for nutritionalcounseling.

Other obesity services outside of mandated EPSDTservices are not explicitly mentioned.

Payment by NMAP will not be approved for: Drugs or items prescribed or recommended for

weight control and/or appetite suppression

Prior authorization required for:Gastric bypass surgery for obesity which includes thefollowing procedures:a. Gastric bypass;b. Gastric stapling; andc. Vertical banded gastroplasty

Non-covered services include: Ileal bypass or any other intestinal surgery for the

treatment of obesity

NMAP will not make payment for services providedwhen the sole diagnosis is "obesity". Obesity itself cannotbe considered an illness. The immediate cause is a caloricintake which is persistently higher than caloric output.When obesity is the only diagnosis, treatment cannot beconsidered reasonable and necessary for the diagnosis ortreatment of an illness or injury.

While obesity is not itself considered an illness, there areconditions which can be caused by or aggravated byobesity. This may include, but is not limited to thefollowing: hypothyroidism, Cushing's disease,hypothalamic lesions, cardiac diseases, respiratorydiseases, diabetes, hypertension, and diseases of theskeletal system. Treatment for obesity may be coveredwhen the services are an integral and necessary part of acourse of treatment for another serious medical condition.


39

NEVADADepartment of Health and Human Services, Division of Health Care Financing & Policy


Adults: The following preventive health services are coveredby Medicaid for men and women:

Healthy diet counseling and obesity screening and counseling.

The USPSTF recommends intensive behavioral dietarycounseling for adult patients with hyperlipidemia and otherknown risk factors for cardiovascular disease and diet-relatedchronic diseases. Intensive counseling can be delivered byprimary care clinicians or by referral to specialists, such asnutritionists or dieticians.

USPSTF recommends that clinicians screen all adult patientsfor obesity and offer intensive counseling and behavioralintervention to promote sustained weight loss for obese adults.

CPT Codes: 96150-96154, 98960-98962


The Nevada Medicaid Drug Rebate program will notreimburse for the following pharmaceuticals: Agents used for weight loss.


Bariatric Surgery is a covered Nevada Medicaid benefitreserved for recipients with severe and resistant morbidobesity in whom efforts at medically supervised weightreduction therapy have failed and who are disabled fromthe complications of obesity. Morbid obesity is definedby Nevada Medicaid as those recipients whose BodyMass Index (BMI) is 35 or greater, and who havesignificant disabling comorbidity conditions which arethe result of the obesity or are aggravated by the obesity.

This benefit includes the initial work-up, the surgicalprocedure and routine post surgical follow-up care.The surgical procedure is indicated for recipients betweenthe ages of 21 and 55 years with morbid obesity.(Potential candidates older than age 55 will be reviewedon a case by case basis.)

Documentation supporting the reasonableness andnecessity of bariatric surgery must be in the recipient’srecord and submitted with the PA.

Coverage is restricted to recipients with the followingindicators:

BMI of 35 or greater; Waist circumference of more than 40 inches in

men, and more than 35 inches in women; Obesity related comorbidities that are

disabling; Strong desire for substantial weight loss; Be well informed and motivated; Commitment to a lifestyle change; Negative history of significant

psychopathology that contraindicates thissurgical procedure.

40

NEW HAMPSHIREDepartment of Health and Human Services



CPT Codes: 96150-96155, 99401-99404, 99411-99412


Requires clinical prior authorization for anti-obesity medication.


Prior authorization criteria not found.

41

NEW JERSEYNJ FamilyCare



CPT Codes: 96150-96155, 97802-97803


The following classes of prescription drugs or conditionsare not covered under the New Jersey Medicaid or NJFamilyCare fee-for-service programs: Antiobesics and anorexiants, with the exception of

lipase inhibitors, when used in treatment of obesity(see N.J.A.C. 10:51-1.14, Prior authorization);coverage of lipase inhibitors shall be limited to obeseindividuals with a Body Mass Index (BMI) equal toor greater than 27 kg/m2 and less than 30 kg/m2 withco-morbidities of hypertension, diabetes ordyslipidemia; and obese individuals with a BMIequal to or greater than 30 kg/m2 withoutcomorbidities

Surgical operations, procedures, or treatment of obesityshall not be covered except when specifically approvedby the HMO

42

NEW MEXICOHuman Services Department


Adults:New Mexico Medicaid does not provide coverage forthe following:

1. Services not considered medically necessary for thecondition of the recipient;

2. Dietary counseling for the sole purpose of weightloss;

3. Weight control and weight management programs;and

4. Commercial dietary supplements or replacementproducts marketed for the primary purpose of weightloss and weight management.

CPT Codes: 97802-97804, 96153-96154


General excluded services include: weight loss/weight control drugs

Bariatric surgery services are only covered whenmedically indicated and alternatives are not successful.

43

NEW YORKDepartment of Health



CPT Codes: 98960-98962, S9445-S9446

EPSDT:Children and adolescents with asthma, diabetes, or otherchronic health conditions who are also obese oroverweight should be counseled about healthy dietaryregimens, or referred to a physician who specializes innutritional issues. These children may benefit fromintense nutritional counseling in combination withmental health and family counseling support.


The following are examples of drugs/drug uses which arenot reimbursable by Medicaid: Drugs whose sole clinical use is the reduction of

weight

Effective May 1, 2014 New York State no longerrequires that covered bariatric surgery procedures forMedicaid beneficiaries be performed in hospitals that theCenter for Medicare and Medicaid Services (CMS)minimum facility standards, and are designated either bythe American College of Surgeons or the AmericanSociety for Metabolic and Bariatric Surgery as aMedicare approved facilities for bariatric surgery. Forcovered bariatric surgeries performed on or after May 1,2014, all hospital will be reimbursed for bariatric surgicalservices for Medicaid Fee for Service and managed carebeneficiaries.

44

NORTH CAROLINADepartment of Health and Social Services



CPT Codes: 96150-96151, 99404, 99412, 97802-97803


The following is a list of services not covered byMedicaid or NCHC when billed under the OutpatientPharmacy Program: Weight loss and weight gain drugs


NC Medicaid (Medicaid) recipients shall be enrolled onthe date of service and may have service restrictions dueto their eligibility category that would make themineligible for this service.

NC Health Choice (NCHC) recipients, ages 6 through 18years of age, shall be enrolled on the date of service to beeligible, and shall meet policy coverage criteria, unlessotherwise specified.

Procedures, products, and services related to this policyare covered when they are medically necessary

Prior authorization criteria not found.

45

NORTH DAKOTADepartment of Human Services


Adults:Nutritional services are allowed up to four (4) visits percalendar year without prior authorization

Medicaid does not pay for: Exercise classes Nutritional supplements for the purpose of weight

reduction Instructional materials and books

CPT Codes: 96150-96152, 96154, 97802-97804, 99078


Drugs which are limited or excluded by the state orfederal law. These include: Agents when used for anorexia or weight gain

Orlistat is covered, by prior authorization, with dietitianevaluation, for recipients with a body mass index of 40 orgreater (height and weight must be supplied). Updates onprogress are required semi-annually with coverageterminated if no progress is shown (specifically 5%weight loss in 6 months) or coverage continuing as longas progress is made until the BMI falls below 30.


Weight loss surgery requires prior authorization fromNorth Dakota Health Care Review, Inc. and must beprovided in writing at least four (4) weeks in advance.

Criteria for coverage include:1. BMI >40 (a BMI >35 may be considered withpresence of serious comorbidity);2. Failure of obesity management programs to achieveweight loss over the past five (5) years (the weightloss program should be documented monthly andsupervised by a physician or professional).Documentation of weight/year for the last five (5) yearsis required. Chart notes for the last three (3) years from aPCP plus documentation of participation in a supervisedprogram need to be submitted;3. Presence of severe disease condition(s) due to obesitythat are not adequately controlled with current medicaltreatment;4. Active participation in their medical management;5. A formal psychiatric evaluation performed by aspecialist (psychiatrist/psychologist) demonstratingemotional stability over the past year; and6.Documentation from surgeon stating the patient isable to tolerate the procedure and is willing to complypostoperatively both physical and psychologically.

46

OHIODepartment of Job & Family Services


Adults:Medicaid-covered preventive medicine services mayinclude, but are not necessarily limited to: Screening and counseling for obesity provided

during an evaluation and management or preventivemedicine visit; and

Medical nutritional therapy

CPT Codes: 99402-99404, 97802-97804, S9470, S9452

EPSDT:Screening components of the healthchek (EPSDT) visitshall be provided to individuals at ages and atfrequencies in accordance with American academy ofpediatrics recommendations for preventative pediatrichealth care (March, 2000), www.aap.org.


Drugs that fall into one of the following categories arenon-covered by the Ohio medicaid pharmacy program: Drugs for the treatment of obesity.

Non-covered procedures include: Treatment of obesity, including but not limited to

gastroplasty, gastric stapling, ileo-jejunal shunt, orother gastric restrictive procedures.

47

OKLAHOMASoonerCare


Adults:Payment is made for six hours of medically necessarynutritional counseling per year by a licensed registereddietician. All services must be prescribed by a physician,physician assistant, advanced practice nurse, or nursemidwife and be face to face encounters between alicensed registered dietitian and the member. Servicesmust be expressly for diagnosing, treating or preventing,or minimizing the effects of illness. Nutritional servicesfor the treatment of obesity is not covered unless there isdocumentation that the obesity is a contributing factor inanother illness.

CPT Codes: 96150-96155, 97802-97804, 98960-98962,S9445

EPSDT:Payment is made for medically necessary nutritionalcounseling as described above for adults. Nutritionalservices for the treatment of obesity may be covered forchildren as part of the EPSDT benefit.

The following drugs, classes of drugs, or their medicaluses are excluded from coverage: Agents used primarily for the treatment of anorexia

or weight gain. Drugs used primarily for thetreatment of obesity, such as appetite suppressantsare not covered. Drugs used primarily to increaseweight are not covered unless otherwise specified.


The approval for a SoonerCare Member to have bariatricsurgery requires two Prior Authorizations.1. Potential Candidacy Prior Authorization2. Bariatric Surgery Prior Authorization

The covered procedure for bariatric surgery is theLaparoscopic Banded Gastroplasty and the Roux-en-Yprocedure.


48

OREGONOregon Health Plan


Adults:Non-covered services include weight loss programs,including, but not limited to, Optifast, Nutrisystem, andother similar programs. Food supplements will not beauthorized for use in weight loss

Medical treatment of obesity is limited to acceptedintensive counseling on nutrition and exercise, providedby health care professionals. Intensive counseling isdefined as face to face contact more than monthly.Visits are not to exceed more than once per week.Intensive counseling visits (once every 1-2 weeks) arecovered for 6 months. Intensive counseling visits maycontinue for longer than 6 months as long as there isevidence of continued weight loss. Maintenance visitsare covered no more than monthly after this intensivecounseling period.

CPT Codes: 96150-96154, 99401-99404, 99411-99412,97802-97804, S9470, 99078


Agents used for weight loss are not covered by theOregon Health Plan


Bariatric surgery for obesity is covered for: individuals 18years and older with a BMI >35 with type II diabetes or another

significant comorbidity or BMI >40 without a significant comorbidity. The individual must have no prior history of roux-

en-Y gastric bypass or laparoscopic adjustablegastric banding, unless in failure due tocomplications of the original surgery.

The individual must also participate inpsychological, medical, surgical, and dieticianevaluations.

The individual must also participate in post-surgicalevaluations.


49

PENNSYLVANIADepartment of Public Welfare



CPT Codes: 96150-96154, S9451, S9470


Non-compensable services and items include drugs andother items prescribed for obesity, appetite control, orother similar or related habit-altering tendencies.

Non-covered services include:

gastroplasty for morbid obesity, gastric stapling orileojejunal shunt, except when all other types oftreatment of morbid obesity have failed

50

RHODE ISLANDDepartment of Human Services



CPT Codes: 97802-97804


Prior Authorization is required for all drugs not includedwithin the scope of the Medical Assistance Program. Aprior authorization form must be signed by theprescribing provider and forwarded to the pharmacywhere the prescription is to be filled. The pharmacist willthen submit to the Medical Assistance Program this formfor approval. Approval will be granted on the basis of therequired information that was supplied. This priorapproval will last for the duration of the prescription.

In general, the types of drugs not included are thefollowing:

Anorexiants (all types, limited to a three-monthapproval only)


Bariatric surgery is performed for long term weightmanagement in individuals diagnosed with severe ormorbid obesity. Two categories of procedures areapplicable:

1) Gastric-restrictive procedures designed to createa small gastric pouch resulting in weight lossproduced by early satiety and decreased caloricintake.

2) Malabsorptive procedures designed to result inweight loss by altering the normal transit of foodthrough the intestine and subsequentmalabsorption.

3) Combination procedures may incorporateelements of both therapeutic processes.


51

SOUTH CAROLINADepartment of Health and Human Services


Adults:Obesity is now recognized as a disease state. Policy iscurrently being written and will be published at a laterdate. The following services are non-covered byMedicaid:• Supplemental fasting• Intestinal bypass surgery• Gastric balloon for treatment of obesity

KePRO must preauthorize all claims for these services.Approval will be based on medical records that documentestablished criteria.

CPT Codes: 96150-96154, 99401-99404, 97802,S9445, S9446, S0316, S9470


Excluded products: Weight control products (except for lipase inhibitors)

Lipase inhibitors require prior authorization.

Xenical(orlistat) for diagnosis of morbid obesity:•Patient must have a diagnosis of obesity in thepresence of other risk factors (e.g., hypertension,diabetes, dyslipidemia).•Patient must have an initial body mass index (BMI)>30kg/m2.•Patient must be on a reduced fat and calorie dietwith nutritional counseling regarding adherenceto dietary guidelines.


Gastric bypass surgery and vertical-banded gastroplastyare performed for patients with extreme obesity. Gastricbypass surgery or vertical-banded gastroplasty for morbidobesity may be covered by Medicaid if both of thefollowing conditions are met:

• It is medically necessary for the individual to have suchsurgery.• The surgery is to correct an illness that caused theobesity or was aggravated by the obesity.

Prior authorization is required from the QIO, KePRO.InterQual screening criteria applies. An annual evaluationwill be required for all individuals who receive gastricbypass surgery or vertical-banded gastroplasty. Thisevaluation will be used by Medicaid to assess the long-term effectiveness of these procedures in the treatment ofobesity.

52

SOUTH DAKOTADepartment of Social Services


Adults:Non-covered services include gastric bypass, gastric stapling,gastroplasty, any similar surgical procedure, or any weight lossprogram or activity

CPT Codes: 96150-96154, 99401-99402


Non-covered services include: Agents used for anorexia, weight loss or weight gain.


Gastric surgery for weight loss is covered when it is an integraland necessary part of a course of treatment for another illnesssuch as cardiac disease, respiratory disease, diabetes, orhypertension and the individual meets all of the followingcriteria: The individual is severely obese with Body Mass Index

(BMI) over 40 and is at least 21 years of age. There is a significant interference with activities of daily

living. There is documented conservative (non-surgical)

promotion of weight loss by a physician supervised weightloss program. Dietician consult is recommended, ifavailable, and the individual must have documentation of 4consecutive monthly visits with their primary carephysician to monitor compliance with, and results of, aconservative weight loss program.

The recipient is motivated and well-informed. Therecipient is free of significant systemic illness unrelated toobesity, is not actively abusing drugs or alcohol, and doesnot use tobacco or if a tobacco user has discontinued usefor 4 months documented in the medical record.

It is medically and psychologically appropriate for theindividual to have such surgery.

The procedure will be performed at a Medicare approvedCenter of Excellence in South Dakota and if lapband/gastric banding procedure has been approved by theSouth Dakota Medical Assistance Program the follow-upadjustments must be performed by the surgeon who did theoriginal surgery or a surgical partner in that practice.


53

TENNESSEETENNCare


Adults:Services, products, and supplies that are specificallyexcluded from coverage under the TennCare program.Weight loss or weight gain and physical fitnessprograms 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 inweight loss programs or for weight gain

Health clubs, membership fees (e.g., YMCA) Marathons, activity and entry fees Swimming pools

CPT Codes: TennCare is a series of managed care planswith individual fee schedules (individuals should contacttheir respective MCO provider as coverage may vary).


Excluded products include: Agents when used for anorexia, weight loss, or

weight gain

Bariatric Surgery, defined as surgery to induce weightloss is covered when medically necessary and inaccordance with clinical guidelines establishedby the Bureau of TennCare.

Acceptable bariatric surgical procedures include Roux-en-Y Gastric and Biliopancreatic Diversion withDuodenal Switch. Gastric stapling is not an acceptablebariatric procedure.

54

TEXASHealth and Human Services Commission


Adults:Medical nutrition counseling services for the diagnosisof obesity without a comorbid condition is not abenefit.

A wide variety of medical nutrition services areavailable, from individual to group therapy, and aredetailed in-depth within the full source.

Texas Medicaid Wellness ProgramThe Texas Medicaid Wellness Program is a specialhealth program for people who get Medicaid and havelong-lasting or serious health conditions.People who get traditional fee-for-service Medicaid canjoin the wellness program.Weight control: Clients who have a BMI above 25 willreceive vouchers for a Weight Watchers Program.

CPT Codes: 99078, 96150-96155, 98960

EPSDTObesity services outside of mandated EPSDT servicesare not explicitly mentioned.

Exclusions: Medicaid may deny a request if itdeterminesthe drug is included in one or more of the followingclasses:1)Amphetamines, when used for weight loss, andobesity control drugs.

Bariatric surgery is considered medically necessary when usedas a means to treat covered medical conditions that are causedor significantly worsened by the client’s obesity in cases wherethese morbid conditions cannot adequately be treated bystandard measures unless significant weight reduction takesplace.

Non-covered services include: Intragastric balloon for obesity

55

UTAHDepartment of Health


Adults:Nutritional counseling and an evaluation andmanagement are not covered for the same provider onthe same date of services. Medicaid does not pay twoevaluation and management codes on the same date ofservice. The evaluation and management service may bebilled with a prolonged service code to include the timefor nutritional counseling with supportivedocumentation. Coverage of nutritional counseling formalnutrition or obesity is covered under code S9470 forpregnant adults (14 visits).

CPT Codes: 96150-96155, 99411, 97802-97803,S9470, 99078, S0315, S9446, S9449, S9452


The Social Security Act, Section 1927(d) (2) states: “Thefollowing drugs or classes of drugs, or their medical uses,may be excluded from coverage or otherwise restrictedby a state participating in the master rebate agreement.”1. Agents when used for anorexia, weight loss or weightgain


Surgery for obesity (i.e. gastric bypass, gastroplasty) willbe considered when the patient meets each of the sevenitems below including BMI threshold, age, comorbidies,informed consent, etc.

See source for full criteria.

56

VERMONTOffice of Vermont Health Access (OVHA)


Adults:Medical nutrition therapy services are paid through theenrolled primary care physician, inpatient hospital,outpatient hospital, registered dietitians (RD) and schoolhealth services. Registered Dietitian billing is restrictedto three codes specific to RD services. These servicesare not reimbursable when billed by a physician

CPT Codes: 99401-99404, 97802-97804, 99411-99412


Effective 10/12/2011, anti-obesity agents (weight lossagents) are no longer a covered benefit for all VermontPharmacy Programs. This change is resultant from DrugUtilization Review (DUR) Board concerns regardingsafety and efficacy of these agents.

In addition to the specific exclusions listed elsewhere inVHAP-Limited rules and procedures, benefits will not beprovided for the treatment of obesity, except when:

1. The physician determines that the body mass indexis over 40 (according to Table 1 in the Methods forVoluntary Weight Loss and Control booklet by theNational Institute of Health Technology AssessmentConference Statement of March 1992);

2. There are other medical conditions present whichcould be significantly and adversely affected by thisdegree of obesity; and

3. The DVHA approves the treatment in advance.

57

VIRGINIADepartment of Medical Assistance Services



CPT Codes: 96150-96155, 97802-97803,


Follows disability criteria under Social Security (SSAPublication 64-039) Part III, § 9.09

9.09 Obesity. Weight equal to or greater than the valuesspecified (100 percent above desired level), and one ofthe following:A. History of pain and limitation of motion in any

weight-bearing joint or lumbosacral spine (onphysical examination) associated with findings onmedically acceptable techniques of arthritis in theaffected joint of lumbosacral spine; or

B. Hypertension with diastolic blood pressurepersistenetly in excess of 100 mm. Hg measuredwith appropriate size cuff; or

C. History of congestive heart faulre manifested bypast evidence of vascular congestion such ashepatomegaly, peripheral or pulmonary edema; or

D. Chronic venous insufficiency with superficialvaricositities in a lower extremity with pain onweight bearing and persistent edema; or

E. Respiratory disease with total force vital capacityequal to or less than 2.0 L. or a level of hypoxemiaat rest equal to or less than the values specified inTable-III A or III-B or III-C


Effective April1, 2012 regardless of the dates of service,the provider must submit service authorization requests toKEPRO, BMAS’ Service Authorization contractor.Specific information regarding the service authorizationrequirements can be found in Appendix D.

58

WASHINGTONDepartment of Social and Health Services


Adults:Excluded services include weight reduction and controlservices, procedures, treatments, devices, drugs,products, gym memberships, equipment for the purposeof weight reduction, or the application of associatedservices

The Agency covers medical nutrition therapy whenmedically necessary. Medical conditions that can bereferred to a certified dietitian include, but are notlimited to, the following: Obesity– Use diagnosis codes278.00, 278.01 or 278.02 on your claim.

CPT Codes: 96150-96154, 99401, 97802-97804,99078,


Drugs and indications excluded from coverageby Washington Administrative Code (WAC)such as drugs prescribed for:

Weight loss or gain

The agency covers medically necessary bariatric surgery for eligibleclients. Bariatric surgery must be performed in a hospital with abariatric surgery program and the hospital must be:

a) Located in the state of Washington or approved border citiesb) Meet requirements of WAC 182-55-2301

If bariatric surgery is requested or prescribed under the EPSDTprogram, the agency evaluates it as a covered service under EPSDT’sstandard of coverage that requires the service to be:

a) Medically necessaryb) Safe and effectivec) Non-experimental

The agency authorized payment for bariatric surgery and bariatricsurgery-related services in three steps:

a) Stage One: Initial assessment of clientb) Stage Two: Evaluations for bariatric surgery and successful

completion of a weight loss regimenc) Stage Three: Bariatric surgery

Additional criteria (including physician restrictions) apply – refer tosource for full criteria

59

WEST VIRGINIAMountain Health Choices


Adults:Certain services and items are not covered by theMedicaid Program. Non-covered services include,but not limited to, the following:

Nutritional (dietary) counseling Weight reduction (obesity) clinics/programs.

CPT Codes: 99401-99402, 97802, 99078


The following list of drugs, drug products, and relatedservices are not reimbursable. Non-covered services are noteligible for a West Virginia Department of Health andHuman Resources (WVDHHR) fair hearing. Non-coveredservices include, but are not limited to:

Agents used for weight loss or weight gain


The patient‘s primary care physician or the bariatric surgeon mayinitiate the medical necessity review and prior authorization bysubmitting a request, along with all the required information, to theWest Virginia Medical Institute (WVMI), 3001 Chesterfield Place,Charleston, West Virginia 25304. The West Virginia Medical Institute(WVMI) will perform medical necessity review and prior authorizationbased upon the following criteria:

A Body Mass Index (BMI) greater than 40 must be presentand documented for at least the past 5 years. Submitteddocumentation must include height and weight.

The obesity has incapacitated the patient from normalactivity, or rendered the individual disabled. Physiciansubmitted documentation must substantiate inability toperform activities of daily living without considerabletaxing effort, as evidenced by needing to use a walker orwheelchair to leave residence.

The patient must have a documented diagnosis of diabetesthat is being actively treated with oral agents, insulin, ordiet modification. The rationale for this criteria is takenfrom the Swedish Obese Subjects (SOS) study,International Journal of Obesity and Related MetabolicDisorders, May, 2001

Patient must have documented failure at two attempts ofphysician supervised weight loss, attempts each lasting sixmonths or longer. These attempts at weight loss must bewithin the past two years, as documented in the patientmedical record, including a description of why the attemptsfailed.

The patient must demonstrate ability to comply withdietary, behavioral and lifestyle changes necessary tofacilitate successful weight loss and maintenance of weightloss. Evidence of adequate family participation to supportthe patient with the necessary lifelong lifestyle changes isrequired.

Additional criteria (including physician restrictions) apply – refer tosource for full criteria

60

WISCONSINForwardHealth

NutritionalAssessment/Counseling153,154

Pharmaceutical Therapy155 Bariatric Surgery156

Adults:Weight management services (e.g., diet clinics, obesityprograms, weight loss programs) are reimbursable onlyif performed by or under the direct, on-site supervisionof a physician and only if performed in a physician'soffice. Weight management services exceeding fivevisits per calendar year require PA.

For weight management services, food supplements, anddietary supplies (e.g., liquid or powdered diet foods orsupplements, OTC diet pills, and vitamins) that aredispensed during an office visit are not separatelyreimbursable by Wisconsin Medicaid.

CPT Codes: 99401-99404, S9445

EPSDT:

Obesity services outside of mandated EPSDTservices are not explicitly mentioned.


Covered Drugs: Benzphetamine, Diethylpropion, Phentermine.Phendimetrazine. Qysmia, Xenical®, BelviqClinical criteria for approval of a PA request for anti-obesity drugs require oneof the following:

The member has a BMI greater than or equal to 30.

The member has a BMI greater than or equal to 27 but less than 30 andtwo or more of the following risk factors:

o Coronary heart disease.o Dyslipidemia.

o Hypertension.

o Sleep apnea.o Type II diabetes mellitus.

In addition, all of the following must be true:

The member is 16 years of age or older. (Note: Members need only to be12 years of age or older to take Xenical®.)

The member is not pregnant or nursing.

The member does not have a history of an eating disorder (e.g., anorexia,bulimia).

The prescriber has evaluated and determined that the member does nothave any medical or medication contraindications to treatment with theanti-obesity drug being requested.

For controlled substance anti-obesity drugs, the member does not have amedical history of substance abuse or misuse.

The member has participated in a weight loss treatment plan (e.g.,nutritional counseling, an exercise regimen, a calorie-restricted diet) inthe past six months and will continue to follow the treatment plan whiletaking an anti-obesity drug.

Note: ForwardHealth does not cover the brand name (i.e., innovator) anti-obesity drugs if an FDA-approved generic equivalent is available.ForwardHealth does not cover any brand name innovator phentermineproducts. In addition, ForwardHealth does not cover OTC anti-obesity drugs.

Weight loss targets must be met in specified timeframe or coverage will beterminated. Lifetime caps apply.


Prior authorization requiredAll covered bariatric surgery procedures (CPT procedure codes 43644, 43645,43770-43775, 43843, 43846-43848) require PA. A bariatric procedure thatdoes not meet the PA approval criteria is considered a noncovered serviceThe approval criteria for PA requests for covered bariatric surgery proceduresinclude all of the following: The member has a BMI greater than 35 with at least one documented

high-risk, life limiting comorbid medical conditions capable ofproducing a significant decrease in health status that are demonstratedto be unresponsive to appropriate treatment. There is evidence thatsignificant weight loss can substantially improve the followingcomorbid conditions:

o Sleep apnea.o Poorly controlled Diabetes Mellitus while compliant

with appropriate medication regimen.o Poorly controlled hypertension while compliant with

appropriate medication regimen.o Obesity related cardiomyopathy.

The member has been evaluated for adequacy of prior efforts to loseweight. If there have been no or inadequate prior dietary efforts, themember must undergo 6 months of a medically supervised weightreduction program. This is separate from and not satisfied by thedietician counseling required as part of the evaluation for bariatricsurgery.

The member has been obese for at least 5 years. The member is 18 years of age or older and has completed growth. The member has not had bariatric surgery before or there is clear evidence of compliance with dietary modification and supervised exercise, includingappropriate lifestyle changes, for at least two years. The bariatric center where the surgery will be performed has been approvedby ASBS guidelines as a Center of Excellence and meet one of the followingrequirements:

The center has been certified by the American College of Surgeonsas a Level 1 Bariatric Surgery Center.

The facility has been certified by the ASBS as a Bariatric SurgeryCenter of Excellence.


61

WYOMINGOffice of Healthcare Financing



CPT Codes: 99401-99404, S9470, 99078, S0315-20316, S9445-S9446, 96150-96154


Excluded in legend drug exclusions: Anorexiant products

Prior Authorization required

Procedure Code Range: 43644, 43770, 43842, 43843, 43846, 43848

Medicaid will consider coverage of gastric bypass surgery on adults on acase-by-case basis, with the appropriate documentation, if it is medicallyappropriate for the individual to have such surgery and if the surgery is tocorrect an illness that is aggravated by the obesity

The client must meet the weight criteria for clinically severeobesity, which is BMI>40, or 35-40 with co-morbidconditions. Documentation of the client’s BMI and obesityrelated co-morbid medical conditions exacerbated by theobesity are required

The primary physician must submit a complete client historyand physical examination notes, including a three-year recordof the client’s weight and documented efforts to lose weight byconventional means. Conventional means must describe atleast two different non-surgical programs of dietary regimentsthat include appropriate exercise and a supported behavioralmodification program utilizing licensed mental healththerapists.

Documentation of pre-operative psychological evaluation by apsychiatrist or licensed clinical psychologist affiliated with aclinic (not associated with the physician’s grouprecommending the procedure); within the last 90-days todetermine if the clients has the emotional stability to followthrough with the medical regimen hat must accompany thesurgery


62

Appendix: Mandated EPSDT Services160

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who areenrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services.

States are required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate healthconditions, based on certain federal guidelines. EPSDT is made up of the following screening, diagnostic, and treatment services:

Screening Services

Comprehensive health and developmental history Comprehensive unclothed physical exam Appropriate immunizations (according to the Advisory Committee on Immunization Practices) Laboratory tests (including lead toxicity screening Health Education (anticipatory guidance including child development, healthy lifestyles, and accident and disease prevention)

Other Necessary Health Care ServicesStates are required to provide any additional health care services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct orreduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan. It is the responsibility of states to determine medical necessity ona case-by-case basis.

Diagnostic ServicesWhen a screening examination indicates the need for further evaluation of an individual's health, diagnostic services must be provided. Necessary referrals should be made withoutdelay and there should be follow-up to ensure the enrollee receives a complete diagnostic evaluation. States should develop quality assurance procedures to assure thatcomprehensive care is provided.

TreatmentNecessary health care services must be made available for treatment of all physical and mental illnesses or conditions discovered by any screening and diagnostic procedures.

Periodicity SchedulePeriodicity schedules for periodic screening, vision, and hearing services must be provided at intervals that meet reasonable standards of medical practice. States must consult withrecognized medical organizations involved in child health care in developing their schedules. Alternatively, states may elect to use a nationally recognized pediatric periodicityschedule (i.e., Bright Futures). A separate dental periodicity schedule is also required.

Some studies have shown that EPSDT ostensibly already covers obesity-related services but provider confusion due to lack of guidance and prior authorization requirements orother administrative hurdles may discourage benefit uptake.161

63

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Note: All electronic sources were visited between September 2014 and November 2014. Not all hyperlinks may be accessed as weblinks and some may have changed sincethis data was compiled.

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Available at: http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/HANDBOOKS/Practitioner Services Handbook_Adoption.pdf31 Georgia Department of Community Health. Policies and Procedures for Physician Services. Last updated Oct 2013. Accessed November 17 2014. Available at:https://www.mmis.georgia.gov/portal/PubAccess.Provider Information/Provider Manuals/tabId/54/Default.aspx32 Georgia Department of Community Health: Division of Medical Assistance. Policies and Procedures for Pharmacy Services. Last updated October 20134. AccessedNovember 17 2014. Available eat: https://www.mmis.georgia.gov/portal/PubAccess.Provider Information/Provider Manuals/tabId/54/Default.aspx33 Georgia Medicaid Wellcare. Bariatric Surgery Policy Number: HS-006. Updated on Feb 2012. Accessed on Nov 5, 2013. Accessed November 17 2014. Available at:https://www.wellcare.com/WCAssets/corporate/assets/HS006_Bariatric_Surgery.pdf34 Hawaii Department of Human Services. Medicaid Provider Manual: EPSDT. Last updated Mar 2011. Accessed November 17 2014. Available at: http://www.med-quest.us/providers/ProviderManual.html35 Hawaii Department of Human Services. Provider Manual: Appendix 6. Last updated Jan 1 2011. Accessed November 17 2014. Available at: http://www.med-quest.us/providers/ProviderManualapp.html - Providerspmaopp0636 Hawaii Department of Human Services. Medicaid Provider Manual: Medical Surgical Services. Accessed November 17 2014. Available at: http://www.med-quest.us/providers/ProviderManual.html37 Idaho Department of Health and Welfare. Idaho MMIS Provider Handbook: Dietary and Nutrition Service Providers. Last update Aug 2010. Accessed November 172014. Available at: https://www.idmedicaid.com/Provider Guide/Forms/AllItems.aspx?RootFolder=%2fProvider Guide%2fProviderHandbook&FolderCTID=&View=%7B67788BEB-2A13-4FCD-AC01-C1CC9F086678%7D

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Minnesota Department of Human Services. MHCP Provider Manual, Medical Nutritional Therapy. Last updated Aug 2012. Accessed November 17 2014. Available at:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_00892668 Minnesota Department of Human Services. Pharmacy Provider Manual. Last updated: Aug 13 2013. Accessed November 17 2014. Available at:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_13771369 Minnesota Department of Human Services. Physician and Professional Services. Updated on Oct 2013. Accessed November 17 2014. Available at:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_008926#P724_5709770 Mississippi Admin Code. Fee Schedule. Accessed November 20, 2014. Available at: http://www.medicaid.ms.gov/providers/fee-schedules-and-rates/#fee71

Mississippi Division of Medicaid. Administrative Code. Accessed November 20, 2014. Available at: http://www.medicaid.ms.gov/providers/administrative-code/72 Mississippi Division of Medicaid. Administrative Code: Title 23: Medicaid Part 200 General Provider Information. Accessed November 20, 2014. Available at:http://www.medicaid.ms.gov/providers/administrative-code/73 Missouri Department of Social Services. MO HealthNet Physician Manual: Section 13.55 Updated: April 2014. Accessed November 17 2014. Available at:http://207.15.48.5/collections/collection_phy/Print.pdf74 MO HealthNet. New Drug List. Last updated October 13 2014. Accessed November 17 2014Available at: http://www.dss.mo.gov/mhd/cs/pharmacy/pdf/druglist.pdf75 Missouri Department of Social Services. MO HealthNet Manuals: Section 13.33 .J Updated: April 2014. Accessed November 17 2014. Available at:http://207.15.48.5/collections/collection_phy/Print.pdf76 Montana Department of Health and Human Services. General Information for Providers. Section 2.2-2.10 Last updated November 2014. Accessed November 17 2014.Available at: http://medicaidprovider.hhs.mt.gov/pdf/manuals/physician07012014.pdf77

Montana DPHHS. Prescription Drug Program Provider Manual. Last updated September 2013. Available at:http://medicaidprovider.hhs.mt.gov/providerpages/providertype/19.shtml78

Montana DPHHS. Medicaid Member Guide. Last Updated November 2014. Accessed on Nov 17, 2014. Available at:http://medicaidprovider.hhs.mt.gov/pdf/manuals/physician07012014.pdf79 Nebraska Department of Social Services. Provider Manual 471 NAC 33-000. Last updated Mar 1996. Accessed September 30, 2014. Available at:http://dhhs.ne.gov/medicaid/Pages/med_phphys.aspx

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80 Nebraska Medicaid Program. Provider Information Pharmacy Provider Handbook. 16-003. Last updated March 2012. Accessed September 30, 2014. Available at:http://dhhs.ne.gov/medicaid/Pages/med_phphar.aspx81 Nebraska Department of Health and Human Services. Physician Handbook: Chapter 18. Last updated September 2009. Accessed September 30, 2014. Available at:http://dhhs.ne.gov/medicaid/Pages/med_phphys.aspx82 Nevada Department of Health and Human Services. Provider Type 20 Physician Reimbursement Rates. Updated August 2014. Accessed September 30, 2014. Availableat: https://dhcfp.nv.gov/MSM Table of Contents.htm?Accept83 Nevada Department of Health and Human Services: Division of Health Care Financing and Policy. Prescribed Drugs. Section 1203. Last updated June 2013. AccessedSeptember 30, 2014. Available at: https://dhcfp.nv.gov/MSM Table of Contents.htm?Accept84 Nevada Medicaid. Medicaid Services Manual Chapter 600-Physician Services- Attachment A. Updated on Sept 2013. Accessed on September 30, 2014. Available at:http://dhcfp.nv.gov/MSMTableofContents.htm?Accept85 New Hampshire Department of Health and Human Services. Updated July 2014. Accessed October 1, 2014. Available at: http://nhmmis.nh.gov/portals86 New Hampshire Department of Health and Human Services. Clinical Prior Authorization Program. Updated August 2012. Accessed October 1, 2014. Available at:http://www.dhhs.nh.gov/ombp/pharmacy/authorization.htm87 New Hampshire Medicaid. Physician Request for Prior Authorization for Certain Surgical Procedures. Updated July 2013. Accessed October 1, 2014. Available at:http://www.nhmedicaid.kepro.com88 N.J.A.C. 10:49-5.7: Services Covered by Medicaid and the NJ FAMILYCARE Programs. Updated September 2014. Accessed October 1, 2014. Available at:http://www.njmmis.com/downloadDocuments/CPTHCPCSCODES.pdf89 N.J.A.C. 10:51-1.13: Pharmaceutical Services. Updated September 2014. Accessed October 1, 2014. Available at: http://www.lexisnexis.com/hottopics/njcode/90 N.J.A.C. 10:49-5.7: Services Covered by Medicaid and the NJ FAMILYCARE Programs. Updated September 2014. Accessed October 1, 2014. Available at:http://web.lexisnexis.com/research/xlink?app=00075&view=full&interface=1&docinfo=off&searchtype=get&search=N.J.A.C.+10%3A49-5.791 NM Fee Schedule. Updated July 2014. Accessed October 3, 2014. Available at: http://www.hsd.state.nm.us/providers/fee-for-service.aspx92 NM Admin Code 8.324.4.14. Updated September 2014. Accessed October 3, 2014. Available at: http://www.hsd.state.nm.us/providers/overview-2.aspx93 NM Admin Code 8.310.2.13. Updated September 2014. Accessed October 3, 2014. Available at: http://www.hsd.state.nm.us/providers/overview-2.aspx94 New York State Department of Health: Office of Medicaid Management. Physician Provider Manual. Updated August 2014. Accessed October 3, 2014. Available at:https://www.emedny.org/ProviderManuals/Physicians/index.aspx95 NY Pharmacy Manual: Provider Guidelines. Updated September 2013. Accessed October 3, 2014. Available at:https://www.emedny.org/ProviderManuals/Pharmacy/index.aspx96 New York State Department of Health. New York State Medicaid Update. Updated June 2014. Accessed on Oct 3, 2014. Available at:http://www.health.ny.gov/website/health_care/medicaid/program/update/2014/2014-06.htm#bar97 NC Division of Medical Assistance. Fee Schedule. Updated April 2014. Accessed October 6, 2014. Available at: http://www.ncdhhs.gov/dma/fee/index/htm98 NC Division of Medical Assistance. Outpatient Pharmacy Clinical Coverage Policy 9.4. Updated September 2013. Accessed October 3, 2014. Available at:http://www.ncdhhs.gov/dma/mp/99 North Carolina Division of Medical Assistance Medicaid and Health Choice. Surgery for Clinical Severe or Morbid Obesity: Clinical Coverage Policy No: 1A-15. UpdatedJune 2012. Accessed on October 3, 2014. Available at: http://www.ncdhhs.gov/dma/mp/1a15.pdf100 North Dakota Department of Human Services: Medical Services Division. Fee Schedule. Updated July 2014. Accessed October 6, 2014. Available at:http://www.gov/dhs/services/medicaidsew/medicaid/providerfeeschedules.html101 North Dakota Department of Human Services. General Information for Providers: Medicaid and Other Assistance Programs Last updated Apr 2012. Accessed October6,2014. Available at: http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/gen-info-providers.pdf102 ND Department of Human Services. Provider Manual for Pharmacies. Last updated April 2010. Visited Oct 15 2013. Available at:http://www.nd.gov/dhs/services/medicalserv/medicaid/provider-all.html103 North Dakota Health Care Review, Inc. Criteria for Bariatric Surgery. Updated January 2008. Accessed October 6, 2014. Available at:http://www.ndhcri.org/Healthcare_Professionals/medicaidcasereview/preauthorizationareas.html

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104 Ohio Admin Code. Physician Contract Fee Schedules. Updated October 2014. Accessed October 7, 2014. Available at:http://portal.ohmits.com/Public/Public%20Information/Fee%20Schedules/tarbId/55/Default.aspex105 Ohio Admin Code. 5160-14. Updated July 2006. Accessed October 7, 2014. Available at: http://codes.ohio.gov/oac/5160-14106 Ohio Department of Medicaid. Admin Code 5160-9. Updated October 2012. Accessed October 7, 2014. Available at: http://codes.ohio.gov/oac/5160-9-03107 Ohio Admin Code 5160-4. Updated January 2012. Accessed October 7, 2014. Available at: http://codes.ohio.gov/oac/5160-4.108 Okla. Admin. Code 317:30-5-108-1076. Updated August 2014. Accessed October 7, 2014. Available at: http://www.okhca.org/xPolicySearch.aspx109 Oklahoma Health Care Authority. Physician Fee Schedule. Updated July 2014. Accessed October 7, 2014. Available at:http://www.okha.org/providers.aspx?id=102&menu=60&parts=7773110 Oklahoma Health Care Authority. Okla. Admin Code 317:30-5-72.1. Updated August 2014. Accessed October 7, 2014. Available at: http://www.oar.state.ok.us111 Okla. Admin Code 317:30-5-137.2. Updated August 2014. Accessed October 7, 2014. Available at: https://www.oar.state.ok/us/oar/codedoc02nsf.frm112 Oregon Health Plan: Division of Medical Assistance Programs. General Rules Admin Handbook 410.120. Updated April 2014. Accessed October 8, 2014. Available at:http://www.oregon.gov/oha/healthplan/policies/120rb040414.pdf113 Oregon Health Plan Fee Schedule. Updated August 2014. Accessed October 8, 2014. Available at: http://www.oregon.gov/oha/healthplan/pages/feeschedule.aspx114 Oregon Health Plan: Division of Medical Assistance Programs. Pharmaceutical Services Program. Accessed October 8, 2014. Available at:http://www.oregon.gov/oha/healthplan/Pages/pharmacy-policy.aspx115 Oregon Health Services Commission. Prioritized List of Health Services. Updated October 2013. Accessed October 8, 2014. Available at:http://www.oregon.gov/oha/herc/Pages/PrioritizedList.aspx116 Pennsylvania Medicaid Physician Fee Schedule. Updated September 2014. Accessed October 21, 2014. Available at:http://www.dpw.state.pa/us/publications/forproviders/schedules/mafeeschedules/outpatientfeeschedule/index.htm117 Pennsylvania Admin Code 1121.54(1). Accessed October 21, 2014.118 Pennsylvania Medicaid. Chapter 1163.59 Inpatient Hospital Services. Updated August 2014. Accessed October 21, 2014. Available at: http://www.pacode.com119 Rhode Island Fee Schedule. Updated July 2014. Accessed October 21, 2014. Available at:http://www.eohhs.ri.gov/ProvidersPartners/BillingampClaims/FeeSchedule.aspx120 Rhode Island Medicaid. Pharmacy Provider Manual. Pharmacy Coverage Policy. Accessed October 21, 2014. Available at:http://www.eohhs.ri.gov/ProvidersPartners/ProviderManualsGuidelines/MedicaidProviderManual/Pharmacy/PharmacyCoveragePolicy.aspx#15.4121 Rhode Island Health and Human Services. Medicaid Provider Manual: Physician. Accessed October 21, 2014.. Available at:http://www.eohhs.ri.gov/ProvidersPartners/GeneralInformation/ProviderDirectories/Pharmacy.aspx122 South Carolina Department of Health and Human Services. Fee Schedules. Updated January 2014. Accessed October 22, 2014. Available at:https://www.scdhhs.gov/resource/fee-schedules123 South Carolina Medicaid. Pharmacy Services Manual. Updated October 2014. Accessed October 22, 2014. Available at:https://www.scdhhs.gov/internet/pdf/manuals/pharm/Section%202.pdf124 South Carolina Department of Health and Human Services. Physicians, Laboratories, and Other Medical Professionals Provider Manual. Updated October 2014.Accessed October 22, 2014. Available at: https://www.scdhhs.gov/internet/pdf/manuals/Physicians/SECTION%202.pdf125 South Dakota Medicaid. Physician Non-Laboratory Services. Updated September 2014. Accessed October 22, 2014. . Available at:http://dss.sd.gov/sdmedx/docs/providers/feeschedules/Physician%20FY15.pdf126 South Dakota Medicaid. Pharmacy Billing Manual. Updated June 2014. Accessed October 22, 2014. Available at:http://dss.sd.gov/sdmedx/includes/providers/billingmanuals/docs/Pharmacy06.19.14.pdf127 South Dakota Department of Social Services. Prior Authorization: Bariatric Surgery. Accessed October 22, 2014. Available at:http://dss.sd.gov/sdmedx/includes/providers/programinfo/pa/bariatric.aspx128 Tennessee Medicaid. Rules of Tennessee Department of Finance and Administration Chapter 1200-13-13. Updated March 2014. Accessed October 23, 2014. Availableat: http://www.tn.gov/sos/rules/1200/1200-13/1200-13-13.20140317.pdf

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129 Tennessee Medicaid. Pharmacy Claims Submission Manual. Updated August 2014. Accessed October 23, 2014. Available at:http://tenncare.magellanhealth.com/static/docs/Program_Information/TN_Medicaid_Pharmacy_Claims_Submission_Manual_Final.pdf130 Tennessee Medicaid. Rules of Tennessee Department of Finance and Administration Chapter 1200-13-13. Updated March 2014. Accessed October 23, 2014. Availableat: http://www.tn.gov/sos/rules/1200/1200-13/1200-13-13.20140317.pdf131 Texas Medicaid Fee Schedule Information. Updated October 2014. Accessed October 23, 2014. Available at:http://public.tmhp.com/FeeSchedules/StaticFeeSchedule/FeeSchedules.aspx132 Texas Medicaid Provider Insurance Manual. Updated October 2014. Accessed October 23, 2014. Available at:http://www.tmph.com/TMPH_File_Library/Provider_Manuals/TMPPM/2014/TMPPM_October_2014.pdf133 Texas Medicaid Fee Schedule Information. Updated October 2014. Accessed October 23, 2014. Available at:http://public.tmhp.com/FeeSchedules/StaticFeeSchedule/FeeSchedules.aspx134 Texas Medicaid Provider Insurance Manual. Updated October 2014. Accessed October 23, 2014. Available at:http://www.tmph.com/TMPH_File_Library/Provider_Manuals/TMPPM/2014/TMPPM_October_2014.pdf135 Utah Medicaid Provider Fee Schedule. Accessed October 27, 2014. Available at: http://health.utah/gov/medicaidstplan/lookuo/FeeSchedule/Download/php136 Utah Medicaid. Pharmacy Services Manual. Updated October 2014. Accessed October 27, 2014. Available at:http://health.utah/gov/medicaidstplan/lookuo/FeeSchedule/Download/php137 Utah Department of Health. Medicaid Information Bulletin. Updated April 2008. Accessed on Oct 27, 2014. Available at:http://medicaid.utah.gov/Documents/manuals/pdfs138 Vermont Medicaid. Provider Manual. Updated October 2014. Accessed October 27, 2014. Available at: http://www.vtmedicaid.com/downloads/manuals.html139 Vermont Medicaid Schedule of Fees for Covered Services. Updated January 2014. Accessed October 27, 2014. Available at: http://dvha.vermont.gov/for-providers/2014-lf-feeschedule.pdf140 Vermont Medicaid. Preferred Drug List (PDL) and Drugs Requiring Prior Authorization (PA). Updated May 2014. Accessed October 27, 2014. Available at:http://dvha.vermont.gov/for-providers/preferred-drug-list-clinical-criteria141 Vermont Department of Health. Access Bulletin Nov 11-03. Updated July 2011. Accessed October 27, 2014. Available at: http://dvha.vermont.gov/budget-legislative/vhap-managed-care-procedures-p4005.pdf142 Virginia DMAS. CPT Codes Part 4. Updated November 2014. Accessed November 10, 2014. Available at: http://www.dmas.virginia.gov/content_pgs/pr-ffs_new.aspx143 Virginia DMAS. Physician/Practitioner Manual: Chapter 4: Covered Services and Limitations. Updated April 2, 2012. Accessed November 10, 2014. Available at:http://www.virginiamedicaid.dmas.virginia.gov144 Virginia DMAS. Physician/Practitioner Manual: Appendix D: Prior Authorizations. Updated March 13, 2013. Accessed November 11, 2014. Available at:http://www.virginiamedicaid.dmas.virginia.gov145 Washington State Health Care Authority. Physician-Related Services Manual. Updated October 2014. Accessed November 10, 2014. Available at:http://www.hca.wa.gov/medicaid/rbrvs/Pages/index.aspx146 Washington State Health Care Authority. Non-Covered Physician-related and Health Care Professional Services. 182-531-0150. Updated February 2014. AccessedNovember 10, 2014. Available at: http://apps.leg.wa.gov/WAC/default.aspx?cite=182-531&full=true#182-531-0100147 Washington State Health Care Authority. Non-Covered Physician-related and Health Care Professional Services. 182-531-0150. Updated February 2014. AccessedNovember 10, 2014. Available at: http://apps.leg.wa.gov/WAC/default.aspx?cite=182-531&full=true#182-531-0100148 Washington State Health Care Authority. WAC 182-531-1600. Bariatric Surgery. Updated February 2014. Accessed November 10, 2014. Available at:http://apps.leg.wa.gov/WAC/default.aspx?cite=182-531149 West Virginia Department of Health and Human Resources. Chapter 519 Practitioner Services. Updated January 2012. Accessed November 10, 2014. Available at:http://www.dhhr.wv.gov/bms/Documents/manuals_Chapter_519_Practitioners.pdf150 West Virginia Department of Health and Human Resources. RBRVS 2014. Updated December 2013. Accessed November 10, 2014. Available at:http://www.dhhr.wv.gov/bms/pages/WV-Medicaid-Physician’s-Fee-Schedules-Draft.aspx

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151 West Virginia Department of Health and Human Resources. Chapter 519 Practitioner Services. Updated January 2012. Accessed November 10, 2014. Available at:http://www.dhhr.wv.gov/bms/Documents/manuals_Chapter_519_Practitioners.pdf152 West Virginia Department of Health and Human Resources. Chapter 519 Practitioner Services. Updated January 2012. Accessed November 10, 2014. Available at:http://www.dhhr.wv.gov/bms/Documents/manuals_Chapter_519_Practitioners.pdf153 Wisconsin ForwardHealth. Wisconsin Medicaid Claims. Updated October 2014. Accessed November 10, 2014. Available at:http://www.forwardhealth.wi.gov/kw/archive/Physician110214.pdf154 Wisconsin ForwardHealth. Physician Fee Schedule. Updated September 2014. Accesesd November 10, 2014. Available at:http://www.forwardhealth.wi.gov/WIPortal/Max%20Fee%20Home/tabid/77/Default.aspx155 Wisconsin ForwardHealth. Wisconsin Medicaid Claims. Updated October 2014. Accessed November 10, 2014. Available at:http://www.forwardhealth.wi.gov/kw/archive/Physician110214.pdf156 Wisconsin ForwardHealth. Wisconsin Medicaid Claims. Updated October 2014. Accessed November 10, 2014. Available at:http://www.forwardhealth.wi.gov/kw/archive/Physician110214.pdf157 Wyoming Department of Health. Fee Schedule. Updated November 2014. Accessed November 10, 2014. Available at: http://wyequalitycare.acs-inc.com/provider_home.html158 Wyoming Department of Health. Medicaid Pharmacy Services Provider Manual. Updated December 2013. Accessed November 10, 2014. Available at:http://www.wymedicaid.org/home/provider-manual?nocache=771:1415636867159 Wyoming Department of Health. CMS 1300 Provider Manual. Updated October 2014. Accessed November 10, 2014. Available at: http://wyequalitycare.acs-inc.com/Medicaid.html160 Medicaid.gov. Early and Periodic Screening, Diagnosis, & Treatment. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-Periodic-Screening-Diagnosis-and-Treatment.html161 Wilensky S, Whittington R and Rosenbaum S. Strategies for Improving Access to Comprehensive Obesity Prevention and Treatment Services for Medicaid-EnrolledChildren. Washington: George Washington University School of Public Health and Health Services, 2006. Available at:http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/index.cfm?mdl=pubSearch&evt=view&PublicationID=3BB37608-5056-9D20-3D751ECC597CE06C