Library: Policy

317:30-5-137. Bariatric surgery

Revised 9-1-21

(a) Bariatric surgery. Gastric bypass and other types of weight-loss surgery, known as bariatric surgery, makes surgical changes to the stomach and digestive system, limits food intake and nutrient absorption, which leads to weight loss.

(b) Eligible providers. Bariatric surgery providers must be:

(1) Certified by the American College of Surgeons (ACS) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) as a Comprehensive Bariatric Surgery Center; or

(2) Currently participating in a comprehensive multidisciplinary bariatric surgery quality assurance program and a clinical outcomes assessment review as a pathway to accreditation; and

(3) Completed a fellowship training in bariatric surgery or be a fellow of the American Society of Metabolic and Bariatric Surgery (ASMBS) or a MBSAQIP verified surgeon; and

(4) Contracted with the Oklahoma Health Care Authority (OHCA); and

(5) Have a demonstrated record of quality assurance.

(c) Documentation. All documentation submitted to request services must demonstrate, through adequate objective medical records, evidence sufficient to justify the member's need for the service, in accordance with OAC 317:30-3-1(f). Documentation requirements include, but are not limited to:

(1) Documents sufficient to show that member is between the ages of fifteen (15) to sixty-five (65);

(2) Psychosocial evaluation;

(3) Independent medical evaluation by a health care professional with dedicated expertise in the care of bariatric surgery patients;

(4) Surgical evaluation by an OHCA-contracted surgeon who is credentialed to perform bariatric surgery;

(5) Record on participation in a nutrition and lifestyle modification program under the supervision of an OHCA contracted medical provider; and

(6) For full guidelines, please refer to www.okhca.org/mau.

(d) Non-covered services.

(1) Procedures considered experimental or investigational are not covered.

(2) The OHCA may withdraw authorization of payment for the bariatric surgery at any time if the OHCA determines that the member, provider, or bariatric program is not in compliance with any of the requirements.

(e) Reimbursement.

(1) Reimbursement shall only be made for services that have been prior-authorized by OHCA or its designee.

(2) To be eligible for reimbursement, bariatric surgery providers must meet the requirements listed in (b) (1) through (5) of this Section.

(3) Payment shall be made at the lower of the provider's usual and customary charge or the OHCA fee schedule for Medicaid compensable services and in accordance with the Oklahoma Medicaid State Plan.