Bariatric Surgery - Gastric Bypass / Roux-en-Y Jejunostomy / Stomach Staple

ADDITIONAL CLINICAL INFORMATION REQUIRED TO REVIEW BARIATRIC SURGERY

  1. Patient's current height, weight, Body Mass Index (BMI) and body frame size.
  2. Medical record documentation of weight showing that the patient has been morbidly obese for the past 3 years.
  3. Medical record documentation of medical conditions that have been exacerbated by morbid obesity including treatment plan interventions and outcomes.
  4. Documentation of 6 or more months of adherence to a professionally supervised weight loss program within the past 3 years. Documentation must be made up of actual progress notes (dictated summary letters will not be accepted). The documentation that will be accepted must be:
  1. Physician office notes from the physician who provided the supervision during the weight loss program. Visits must be no less frequent than 1 time per month.

    OR

  2. Progress notes documenting each visit to a reputable community weight loss program such as; Weight Watchers, local hospital sponsored program or other.
  1. Medical record documentation of history and physical documenting no medical contraindications to the surgery being requested.
  2. Documentation of participation in a preoperative program for a minimum of 3 months. Preoperative programming must include:
  1. Evidence that there is an established primary care physician to coordinate preoperative and postoperative care including long term follow-up.
  2. Consultation with each of the following:
  1. A Board Certified surgeon providing documentation of an initial assessment and an assessment of the members progress at the completion of the surgical preparatory regimen.
  2. A Registered dietician or nutritionist for preoperative nutritional assessment and recommendations for postoperative dietary restrictions and follow-ups.
  3. An exercise therapist for physical activity counseling including activities to increase pulmonary reserve prior to surgery and to provide recommendations for postoperative exercises and plan of care.
  4. A psychiatrist or psychologist experienced in bariatric programming to document:
  1. psychological stability of the patient for safety reasons
  2. the existence of a support system through family or friends
  3. the patients ability to comply with dietary restrictions postoperatively
  4. recommendation for behavior modification, support groups or postoperative counseling.
  1. Progress notes and postoperative recommendations from any or all of the above disciplines that were identified as problem areas during the consultation.
  1. Documentation of your postoperative plan of care including who sees the patient and at what intervals.

Once pre-determination has been made, letters are sent to the Employee, Provider of Service and Primary Care Provider.

Reviewed 11/16/04



Documentation to include actual clinical notes

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