MEDICAID FEE-FOR-SERVICE TREATMENT OF OBESITY INTERVENTIONS Compiled By: Lucas Divine Scott Kahan, M.D., M.P.H. Stephanie David, J.D., M.P.H. Christine Gallagher, M.P.A. Mark Gooding, M.A. Perry Markell Jo Palmer Kate Ogorzaly Sara Cherico 50 State & District of Columbia Survey - 2012 Update - The George Washington University Department of Health Policy 2021 K Street NW, Suite 800 Washington, DC 20006 202-994-4100 · fax 202-994-4040 www.gwhealthpolicy.org
Transcript
MEDICAID FEE-FOR-SERVICETREATMENT OFOBESITY
INTERVENTIONS
Compiled By:Lucas Divine
Scott Kahan, M.D., M.P.H.Stephanie David, J.D., M.P.H.Christine Gallagher, M.P.A.
Mark Gooding, M.A.Perry MarkellJo Palmer
Kate OgorzalySara Cherico
50 State &District of
Columbia Survey
- 2012 Update -
The George Washington UniversityDepartment of Health Policy2021 K Street NW, Suite 800Washington, DC 20006202-994-4100 · fax 202-994-4040www.gwhealthpolicy.org
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Table of Contents
Methodology and Findings………………...………………………………………………………………………………………………………….2
Appendix: Standard EPSDT Coverage……………………………………………………………………………………………………………….62
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Methodology and FindingsMethodology:Research findings are based on an online document review of Medicaid provider manuals, drug formularies, and fee schedules conducted between August 16 and September 10,2012. Findings are categorized into three broad categories: Nutritional Assessment/Consultation, Pharmaceutical Therapy, and Bariatric Surgery. We grouped CPT codes into foursub-categories: preventive counseling, nutritional consultation, disease management and education, and behavioral consultation and therapy. For the EPSDT sub-section, onlyservices in excess of standard EPSDT coverage (refer to the Appendix for CMS regulations concerning EPSDT) are reported.
Findings:Prevention-7 states cover all obesity-related preventive care CPT codes. Of these states, 2 impose restrictions such as limiting the number of reimbursable visits. 20 states cover 1 or moreobesity-related preventive care CPT code. 21 states cover no obesity-related preventive care CPT codes and/or state that obesity-related preventive care services are explicitlyexcluded in respective provider manuals. Coverage for 3 states was undeterminable as their Medicaid programs are administered by multiple insurers.
Nutrition-6 states cover all obesity-related nutritional consult CPT codes. Of these states, 2 impose restrictions such as limiting the number of visits or restricting who can administer theseservices. 22 states cover 1 or more obesity-related nutritional consult CPT code. Of these states, 5 impose restrictions and 2 require prior authorization. 22 states cover no obesity-related nutritional consult CPT codes. Coverage for 1 state was undeterminable.
Disease Management-No states cover all obesity-related disease management CPT codes. 19 states cover 1 or more obesity-related disease management CPT codes. Of these states, 3 imposerestrictions. 30 states cover no obesity-related disease management CPT codes. Coverage for 2 states was undeterminable.
Behavioral Consultation-2 states cover all obesity-related behavioral consult CPT codes. Of these states, 1 imposes restrictions such as medical necessity criteria. 24 states cover 1 or more obesity-relatedbehavioral consult CPT code. Of these states, 2 impose restrictions. 23 states cover no obesity-related behavioral consult CPT codes. Coverage for 2 states was undeterminable.
Pharmaceuticals-12 states cover obesity drugs. Of these states, 10 require prior authorization and 8 impose other restrictions such as requiring a specified percent weight loss in a specifiedtimeframe in order to remain eligible for this benefit. 34 states explicitly exclude obesity drug coverage, with one state expressly citing safety concerns as justification for non-coverage. Coverage for 5 states was undeterminable.
Bariatric Surgery-44 states cover bariatric surgery. Of these states, 36 require prior authorization and 37 require criteria other than BMI alone to determine eligibility. 5 states explicitly excludebariatric surgery. Coverage for 2 states was undeterminable.
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CPT/HCPCS-II code Code description Obesity-related servicePrevention99401-99404 or 99411-99412 Counseling 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 S9470 Medical nutrition therapy (individual or group); nutritional assessmentand intervention by non-physician provider Nutritional counseling
Disease Management
99078 Miscellaneous services; physician educational services to patients ingroup setting
Group counseling for patients withsymptoms/illnesses
S0315-S0316 Health education disease management program; initial and follow-upassessments Health education
S9445-S9446 Patient education, not otherwise specified non-physician provider,individual or group Health education
98960-98962 Education and training for patient self-management, by non-physician Counseling for individuals or groups of patientswith symptoms/illnesses
S9449 Weight management class, non-physician provider Weight management classS9451 Exercise class, non-physician provider, per session Exercise class
CPT/HCPCS-II CodesIn 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.
- = strong evidence of noncoverage (either specifically excluded or absent from provider manuals and fee
schedule)
State Medicaid Coverage of Adult Obesity Treatment Modalities
b Various restrictions apply
c Preauthorization required
+ = strong evidence of coverage
≈ = mixed coverage (evidence one or more service covered)
0 = not mentioned/undetermined
Summary Chart of State Coverage
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Maps of State Coverage
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ALABAMAAlabama Medicaid Agency
Nutritional Assessment/Counseling1,2,3,4,5 Pharmaceutical Therapy6 Bariatric Surgery7,8Adults:Diet instruction performed by a physician is consideredpart of a routine visit.
“Non-billable encounters are visits for face-to-facecontact between a patient and health professional forservices other than those listed above (i.e., visits tosocial worker, LPN). Such services include, but are notlimited to, weight check only or blood pressure checkonly. Non-billable encounters cannot be forwarded toHP for payment.”
Medicaid also does not cover dietitians except forrecipients under 21 years of age.
CPT Codes: 99401-99402
EPSDT:Nutritional services covered under children’s specialtyclinics for children who qualify for EPSDT.
At Well Child check up: Nutritional status must beassessed at each screening visit. Screenings are based ondietary history, physical observation, height, weight,head circumference (ages two and under),hemoglobin/hematocrit, and any other laboratorydeterminations carried out in the screening process. Aplotted height/weight graph chart is acceptable whenperformed in conjunction with a hemoglobin orhematocrit if the recipient falls between the 10th and 95thpercentile.
Medicaid will not compensate pharmacy providers for: Agents when used for anorexia, weight loss, or
weight gain except for those specified by theAlabama Medicaid Agency.
Gastric bypass covered with prior authorization approvalwhen specific medical criteria are met.
Considered cosmetic unless specific medical criteria aremet and with prior authorization.
Bariatric surgical procedures are considered for Medicaideligible recipients between 18 and 64 years of age,effective June 1, 2009.
Prior authorization criteria are not specified in providermanual.
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ALASKADepartment of Health and Social Services
Nutritional Assessment/Counseling9,10,11,12,13 Pharmaceutical Therapy14 Bariatric Surgery15Adults:Weight loss programs, programs to improve overall fitness,and maintenance therapy are not covered services.
CPT Codes: 99401-99404
EPSDT:Complete physical exams, or checkups, are covered until achild turns 21. A complete checkup should include: height and weight measurement; vision, hearing, and dental screening; immunizations, if needed; growth and development assessment; time for parents, children and teens to have questions
answered; age-related information about normal development, food,
health, and safety; and referrals for dental care, vision exams, and WIC,
depending on the patient’s age.
Nutrition services are covered for children under age 21 whoare at high risk nutritionally.
The division will reimburse for outpatient nutrition servicesprovided to a Medical Assistance-eligible recipient under 21years of age who has had an EPSDT screening within the 12months before or one month after service is provided and isdetermined to be at high risk nutritionally by a physician,ANP, or other licensed or certified health care practitioner.Coverage for a child under 21 years of age includes one initialassessment within a calendar year, and up to12 additionalhours within a calendar year for counseling and follow-upcare, unless additional visits are prescribed by a physician,ANP, or other licensed health care practitioner who may orderthose services within the scope of the practitioner’s license.Medical justification is required for prescribed services inexcess of 12 hours per calendar year.
Alaska Medicaid does not cover the following pharmacyservices: Medications used to treat infertility, obesity, or
baldness.
Covered; requires special review.
Special review process not detailed.
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ARIZONAHealth Care Cost Containment System (AHCCCS)
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 is notrequired when the assessment is ordered by the PCP.
The Children’s Rehabilitative Services Program, whichprovides specialty coordinated care to high needEPSDTchildren, excludes eating disorders and obesitycoverage.
Excluded (not included in drug formulary or mentionedin provider manual).
Bariatric surgery is only paid for when other treatmentshave been tried and did not work. You must try othertreatments first, like medication or a weight loss plan(The Contractor may expand on this explanation so it isreflective of the Contractor’s criteria for this service).AHCCCS states that “these treatments are less risky andmay help the beneficiary without surgery.”
EPSDT:Screening- The Arkansas Medicaid Program requiresthat all eligible EPSDT participants under age 21 receiveregularly scheduled examinations and evaluations oftheir general physical and mental health, growth,development and nutritional status.
When a condition is diagnosed through a Child HealthServices (EPSDT) screen and requires treatment servicesnot normally covered under the Arkansas MedicaidProgram, those treatment services will be considered forreimbursement if the service is medically necessary andpermitted under federal Medicaid regulations. The PCPmust request consideration for reimbursement using theEPSDT Prescription/Referral for Medically NecessaryServices/Items Not Specifically Included in theMedicaid State Plan Form DMS-693.
Not explicitly mentioned. Requires prior authorization and: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 anda 17-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 asnecessary)
F. A complete history and physical, documenting:a. beneficiary’s height, weight, and BMIb. 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 addressthese issues:a. Ability to provide, without coercion, informed consent,b. family and social support,c. patient ability to comply with the postoperative care plan
Excluded Procedures: Open adjustable gastric banding Open and laparoscopic sleeve gastrectomy
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CALIFORNIAMedi-Cal
Nutritional Assessment/Counseling22,23,24,25 Pharmaceutical Therapy Bariatric Surgery26Adults:Non-Benefit: May be reimbursed in uniquecircumstances, but only if an approved pre-authorization(TAR) is obtained.
CPT Codes: 96150-96153, 99401, S9470
EPSDT:EPSDT services include all services covered by Medi-Cal.In addition to the regular Medi-Cal benefits, a beneficiaryunder the age of 21 may receive additionally medicallynecessary services with prior authorization and aphysician treatment plan. Nutritional Evaluations andServices are additional services which require prior-authorization (TAR). In addition to the TAR, the providermust also submit the following medical documentation:A. Medical information, which supports the medical
necessity for the requested services;B. Assessment of medical care needs, i.e., nursing care,
and;C. Plan of Treatment signed by a physician.
Not explicitly mentioned. Requires Prior Authorization (Treatment Authorization Request – TAR) and:A. The recipient has a BMI, the ratio of weight (in kilograms) to the square of height (in
meters), of:a. Greater than 40, orb. Greater than 35 if substantial co-morbidity exists, such as life-threatening
cardiovascular or pulmonary disease, sleep apnea, uncontrolled diabetes mellitus, orsevere neurological or musculoskeletal problems likely to be alleviated by the surgery.
B. The recipient has failed to sustain weight loss on conservative regimens. Examples ofappropriate documentation of failure of conservative regimens include but are not limitedto:a. Severe obesity has persisted for at least five years despite a structured physician-
supervised weight-loss program with or without an exercise program for a minimum ofsix months.
b. Serial-charted documentation that a two-year managed weight-loss program includingdietary control has been ineffective in achieving a medically significant weight loss.
C. The recipient has a clear and realistic understanding of available alternatives and how his orher life will be changed after surgery, including the possibility of morbidity and evenmortality, and a credible commitment to make the life changes necessary to maintain thebody size and health achieved.
D. The recipient has received a pre-operative medical consultation and is an acceptablesurgical candidate.
E. The recipient has an absence of contraindications to the surgery, including a majorlife-threatening disease not susceptible to alleviation by the surgery, alcohol orsubstance abuse problem in the last six months, severe psychiatric impairment and ademonstrated lack of compliance and motivation.
F. The recipient has a treatment plan, which includes:a. Pre-and post-operative dietary evaluations and nutritional counseling, counseling
regarding exercise, psychological issues, and the availability of supportive resourceswhen needed
b. Repeat bariatric surgery or surgical revision may be medically necessary to correctcomplications or technical failure including implanted device failure, gastric pouch ofinappropriate size or stricture, fistula, obstruction or other surgical complication.
G. Request for repeat surgery for failure to achieve or sustain weight loss must includedocumentation that the patient has been enrolled in and compliant with the previous post-operative program.
H. Authorization for bariatric surgery will only be approved for a Center for Medicare& Medicaid Services certified Center of Excellence (as designated by the AmericanSociety for Bariatric Surgery or certified Level I Bariatric Surgery Center by theAmerican College of Surgeons).
Covered Procedures:A. Open and laparoscopic Roux-en-Y gastric bypass (RYGBP)B. Open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS)C. Laparoscopic adjustable gastric banding (LAGB) Vertical banded gastroplastyD. Gastric bypassE. Open adjustable gastric banding
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COLORADODepartment of Health Care Policy and Finance
Nutritional Assessment/Counseling27,28,29 Pharmaceutical Therapy Bariatric Surgery30,31Adults:Excluded: Non-benefit services include educationalcounseling or materials (e.g., obesity or diabeticinstructions and materials), obesity control therapy(psychiatry services).
CPT Codes: 99401-99404, 99411-99412
EPSDT:Assesses and covers services related to nutrition andweight:
A. Obtain nutritional status through questions aboutdietary patterns. If the child has a poor diet, provideor refer the parent and child for nutritionalcounseling.
B. As part of the Developmental Assessment, measureand compare the child’s height and weight with thenormal ranges for children of that age.Developmental assessment is part of every EPSDTinitial and periodic examination. The assessmentincludes a range of activities to determine whether achild’s developmental processes fall within anormal range of achievement according to agegroup and cultural background. Diagnostic andEvaluation Clinics are available when additionalassessment, diagnosis, treatment, or follow-up isneeded.
Not explicitly mentioned. Requires Pre-Authorization and Medical Necessity
Eligibility: All currently enrolled Medicaid clients over the age of 16 are eligible for this service.
All four of the criteria listed below must be met in order to authorize bariatric surgery. Clients notmeeting the criteria, who have one or more immediate, life-threatening co-morbidities will beconsidered for approval on a case-by-case basis. The fifth criterion applies to clients under the age of 18.
The client is clinically obese with one of the following:1. BMI of 40 or higher OR BMI of 35-40 with objective measurements documenting one or more of aspecified list of co-morbid conditions.
2. The BMI level qualifying the client for surgery (>40 or >35 with one or more specified comorbidities)must be of at least two years’ duration. A client’s required attempts to lose weight may cause their BMIto fluctuate around the discrete required levels during the two-year period. The two-year period will notnecessarily start over, or be prolonged, under this scenario, but will be decided on a case-by-case basis.
3. The client has made at least one serious (6 months or longer) clinically supervised attempt to loseweight in the past, under the supervision of a registered dietician working in consultation with aphysician, nurse practitioner, or physician’s assistant.
4. Medical and psychiatric contraindications to the surgical procedure have been ruled out through:a. A complete history and physical conducted by or in consultation with the requesting surgeon; and;b. A psychiatric or psychological assessment, conducted by a licensed mental health professional, no
more than three months prior to the requested authorization.
Additional Criterion for Teenagers. For individuals under the age of eighteen, the following must bedocumented: The exclusion or diagnosis of genetic or syndromic obesity, such as Prader-WilliSyndrome; Girls have attained Tanner stage IV breast development; Bone age studies estimate theattainment of 95% of projected adult height.
Covered Procedures:1. Roux-en-Y Gastric Bypass;2. Adjustable Gastric Banding;3. Biliopancreatic Diversion with or without Duodenal Switch;4. Vertical-Banded Gastroplasty;5. Vertical Sleeve Gastroplasty.
Colorado Medicaid will reimburse participating providers for no more than one bariatric procedure perclient lifetime, unless a revision is appropriate. Additional criteria apply for revisions.
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CONNECTICUTDepartment of Social Services
Nutritional Assessment/Counseling32 Pharmaceutical Therapy33,34 Bariatric Surgery35,36Adults:Nutritional assessment and counseling; and behavioralcounseling appear to be covered when “medicallynecessary” but require prior authorization.
EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned.
Any drugs used in the treatment of obesity are notcovered.
The department shall pay providers for surgical servicesnecessary to treat morbid obesity when another medicalillness is caused by, or is aggravated by, the obesity. Suchillnesses shall include illnesses of the endocrine systemor the cardio-pulmonary system, or physical traumaassociated with the orthopedic system. “Morbid obesity"is classified by the International Classification ofDiseases (ICD).
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DELAWAREHealth & Social Services Division of Medicaid & Medical Assistance
Nutritional Assessment/Counseling37,38 Pharmaceutical Therapy39,40 Bariatric Surgery41Adults:Does not appear to be covered except in MCO plan andwhen provided in a FQHC as preventive care for weightconsisting of nutritional assessment and referral.
EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned.
Pharmaceuticals not covered include drugs for obesity. 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.
The DMAP may cover bariatric surgery for treatment ofobesity in adults when the patient’s obesity is causingsignificant illness and incapacitation and when all othermore conservative treatment options have failed.
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DISTRICT OF COLUMBIADepartment of Health Care Finance
Nutritional Assessment/Counseling42,43 Pharmaceutical Therapy44 Bariatric Surgery45Adults:Screening and behavioral counseling for obesity arenon-benefits.
EPSDT:Dietary AssessmentIf information suggests a dietary inadequacy, obesity orother nutritional problems, further assessment isindicated, including: Family, socioeconomic or any community factors; Determining quality and quantity of individual diets
(e.g., dietary intake, food acceptance, meal patterns,methods of food preparation and preservation, andutilization of food assistance programs);
Further physical and laboratory examinations; and Preventive, treatment and follow-up services,
including dietary counseling and nutritioneducation.
The following drugs are excluded from coverage for theDC DHCF Pharmacy Program: Anti-obesity drugs.
Gastric bypass requires written justification and priorauthorization.
Specific criteria not defined.
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FLORIDAAgency for Health Care Administration
Nutritional Assessment/Counseling46,47,48 Pharmaceutical Therapy49 Bariatric Surgery50Adults:At a minimum, the following items must be documentedin the recipient’s medical record:• Present history, including pertinent psychiatric history;• Past history;• Family history;• Dietary history;• Nutritional assessment;• Use of alcohol, drugs, and tobacco; and• List of all known risk factors.
CPT Codes: 99401-99403
EPSDT:A Child Health Check-Up (CHCUP) consists of acomprehensive, preventive health screening performedon a periodic basis on recipients’ birth through 20 yearsof age.
A CHCUP includes: A comprehensive health anddevelopmental history, an assessment of past medicalhistory, developmental history and behavioral healthstatus, unclothed physical exam, nutritional assessment,developmental assessment, updating of routineimmunizations, laboratory tests (including blood leadscreening), vision, hearing, and dental screening(including dental referral), and healtheducation/anticipatory guidance, diagnosis, andtreatment.
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
Nutritional Assessment/Counseling51,52 Pharmaceutical Therapy53 Bariatric Surgery54,55Adults: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) canbe billed as a single service if it was the onlyservice provided that day.
Nutritional Counseling (individual or group)rendered in combination with other clinicservices on a particular day should not be billedseparately.
Nutritional Counseling for WIC-eligiblemembers must be beyond the first two (2)nutrition education contacts.
Nutritional Group Counseling classes must bespecific to client’s nutrition-related medicalcondition and diagnosis.
CPT Codes: None
EPSDT:At a minimum, the Diagnostic, Screening andPreventive Services provider must provide nutritionalcounseling.
Non-covered drugs include agentsused for anorexia or weight gain.
Bariatric Surgery for the treatment of morbid obesity is considered medically necessary when pre-authorized with the following criteria met:1. Presence of morbid obesity, defined as either: Body mass index (BMI)* exceeding 40; OR, BMIgreater than 35 in conjunction with ANY of the following severe co-morbities: Coronary heartdisease; OR, Type 2 diabetes mellitus; OR, Clinically significant obstructive sleep apnea ( i.e.,member meets the criteria for treatment of obstructive sleep apnea; OR, Medically refractoryhypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despiteoptimal medical management);AND;2. Member has completed growth (18 years of age or documentation of completion of bone growth);AND;3. The member must concurrently participate in an organized multidisciplinary surgical preparatoryregimen coordinated by a qualified bariatric surgeon in order to improve surgical outcomes, reducethe potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions.AND;4. Member has participated in a physician-supervised nutrition and exercise program (including alow calorie diet, increased physical activity, and behavioral modification). This physician-supervised nutrition and exercise program must meet ALL of the following criteria: Participation innutrition and exercise program must be supervised and monitored by a physician; AND, Nutritionand exercise program must be 6 months or longer in duration; AND, Nutrition and exerciseprogram must occur within the two years prior to surgery; AND, Participation in physician-supervised nutrition and exercise program must be documented in the medical record by anattending physician who does not perform bariatric surgery. Note: A physician’s summary letter isnot sufficient documentation. Programs such as Weight Watchers®, Jenny Craig® and Optifast®are acceptable alternatives if done in conjunction with physician supervision and detaileddocumentation of participation is available for review. However, physician-supervised programsconsisting exclusively of pharmacological management are not sufficient to meet this requirement.AND;5. Mental health evaluation by a psychiatrist or psychologist to determine any contraindications aslisted below, mental competency and understanding of the nature, extent and possible complicationsof the surgery and ability to sustain dietary behavioral modifications needed to ensure a successfuloutcome of surgery. Contraindicated diagnoses are: active drug abuse, active suicidal ideation,borderline personality disorder, schizophrenia, psychotic disorder, uncontrolled depression, definednon-compliance with previous medical care.
Procedures CoveredOnly the following surgical procedures are covered: Gastric segmentation along its vertical axis with a Roux-en-Y bypass with distal anastomosis
placed in the jejunum Laparoscopic adjustable silicone gastric banding Biliopancreatic Diversion with Duodenal Switch Laparoscopic or open sleeve gastrectomy; laparoscopic longitudinal gastrectomy
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HAWAIIMed-QUEST
Nutritional Assessment/Counseling56,57,58 Pharmaceutical Therapy59 Bariatric Surgery60,61Adults:Preventive risk assessments for adults are covered. Theyare reimbursed as procedures.
CPT Codes:96150-96155
EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned.
Appetite suppressants (anorexics) require priorauthorization. Information on the Request for MedicalAuthorization DHS Form 1144B must include thepatient’s weight and program for weight loss. Other typesof weight loss products such as Meridia may have morespecific prior authorization criteria.
Prior Authorization is required.
Jejuno-ileal bypass procedures for morbid obesity isspecifically excluded.
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IDAHODepartment of Health and Welfare
Nutritional Assessment/Counseling62,63,64 Pharmaceutical Therapy65 Bariatric Surgery66,67Adults:Non-included services: Prevention and health assistancebenefits (includes health/wellness education andintervention services such as disease management,tobacco cessation programs, or weight management).
CPT Codes: 96150-96154, 99401-99404, S9470
EPSDT:Nutritional Services for ChildrenFollowing criteria must be met: 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 when priorauthorized.
Non-surgical treatment for obesity: services inconnection with non-surgical treatment of obesity arecovered only when such services are integral andnecessary part of treatment for another medical conditionthat is covered by Medicaid.
Medicaid will only cover bariatric surgeries, includingabdominoplasty and panniculectomy, when all of thefollowing conditions are met: The participant meets the criteria for morbid obesity
as defined in IDAPA 16.03.09.431 SurgicalProcedures for Weight Loss – Participant Eligibilitythrough 434 Surgical Procedures for Weight Loss –Provider Qualifications and Duties online athttp://adminrules.idaho.gov/rules/2012/16/0309.pdf
The procedure is prior authorized by Qualis Health.If approval is granted, Qualis Health will issue theauthorization number and conduct a length-of-stayreview.
The procedure(s) must be performed in a Medicare-approved bariatric surgery center (BSC) or bariatricsurgery center of excellence (BSCE).
Must be medically necessary. All criteria must be met:1. BMI>40 or BMI>35 with co-morbidities such as
diabetes, hypothyroidism, atheroscleroticcardiovascular disease, or osteoarthritis of the lowerextremities. The serious co-morbid condition mustbe documented by the primary physician who refersthe patient for the procedure, or a physicianspecializing in the patient’s comorbid condition whois not associated by clinic or other affiliation with thesurgeons who will perform the surgery.
2. Other Medical Condition exists: The obesity iscaused by the serious comorbid condition or theobesity could aggravate the participant’s cardiac,respiratory, or other systemic disease.
3. Psychiatric Evaluation
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ILLINOISDepartment of Healthcare and Family Services
Nutritional Assessment/Counseling68,69,70 Pharmaceutical Therapy71 Bariatric Surgery72Adults:Not explicitly mentioned in provider manual; however,reimbursable under physician fee schedule.
CPT Codes: 96150-96155, 97802-97804, 99078
EPSDT:Medical Records for EPSDT services must includenutritional assessments and growth chart.
Nutritional Assessment covered under Well Child visits:There is no one biochemical or physical measurementthat will allow a positive statement of nutritional health.Instead, there are a number of measurements, whichcollectively allow an estimate of such. Components of anutritional assessment include the following:Dietary Evaluation - including record of food intake,diet history including questions to identify unusualdietary practices or eating habits (e.g. prolonged use ofbottle feedings, eating non-food items, etc.) or foodfrequency to identify the frequency of consumption offoods grouped together based on their principal nutrientcontribution; evaluation of breastfeeding.
Prescription pharmacy items that are not covered underthe Medical Assistance Program are: Weight loss drugs.
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.
The medical record must contain the followingdocumentation of medical necessity:• Documentation of review of systems (history andphysical);• Client height, weight and BMI;• Listing of co-morbidities;• Patient weight loss attempts;• Current and complete psychiatric evaluation indicatingthe patient is an appropriate candidate for weight losssurgery;• Documentation of nutritional counseling.
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INDIANAOffice of Medicaid Policy and Planning
Nutritional Assessment/Counseling73,74 Pharmaceutical Therapy75,76,77 Bariatric Surgery78Adults:Not explicitly mentioned in provider manual; however,reimbursable under physician fee schedule.
EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned.
Amphetamines are excluded when prescribed for weightcontrol or treatment of obesity.
Anorectics (except amphetamines), both legend andnonlegend, are not covered by Medicaid. Amphetaminesare not covered services for weight control or treatmentof obesity.
Medicaid does not cover anorectics or any agent used topromote weight loss.
Services requiring prior authorization include weightreduction surgery, including gastroplasty and relatedgastrointestinal surgery.
Prior authorization requirements are not defined in theprovider manual.
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IOWADepartment of Human Services
Nutritional Assessment/Counseling79,80,81 Pharmaceutical Therapy82 Bariatric Surgery83,84Adults:Not explicitly mentioned in provider manual; however,reimbursable under physician fee schedule.
EPSDT:Nutritional counseling services provided by licenseddietitians for members age 20 and under are coveredwhen a nutritional problem or a condition of suchseverity exists that nutritional counseling beyond thatnormally expected as part of the standard medicalmanagement is warranted.
Nutritional counseling for children from birth throughage 20 is technically not a “non-inpatient” service, but ispaid similarly. When billing the service, one unit equals15 minutes.
Medicaid payment will not be made for drugs used tocause anorexia, weight gain or weight loss.
Hospital admissions and certain surgical procedures,including surgery for obesity, are subject to priorapproval by the IME Medical Services Unit.
Surgical procedures affect health care expendituressignificantly. To ensure that procedures are medicallynecessary, the IME Medical Services Unit conductspreprocedure review for the Medicaid program.Preprocedure review will be performed for all proceduresidentified on the following list: includes gastric stapling(gastroplasty) and high gastric bypass.
Specific prior authorization documentation requirementsare not defined.
27
KANSASKansas Health Policy Authority
Nutritional Assessment/Counseling85,86,87 Pharmaceutical Therapy88,89 Bariatric SurgeryAdults:Services Requiring Referral from the HealthConnectPrimary Care Case ManagerThe following nonemergency services are not covered ifprovided or prescribed by a provider other than theassigned PCCM unless the PCCM makes a referral. Dietitian
EPSDT:Dietitian Services Dietitian services are covered when provided by a
registered dietitian licensed through the KansasDepartment of Health and Environment (KDHE).Proof of licensure is required at the time ofenrollment.
Dietitian services are covered for KBH participantsonly.
Other insurance and Medicare are primary and mustbe billed first.
Dietitian services can only be rendered as a result ofa medical or dental screening referral.
Individual-focused services are limited to an initialevaluation (up to 2 units) and 11 follow-up units perbeneficiary, per year. Each unit equals 15 minutes.Additional visits may be covered with approvedprior authorization. Refer to Section 4300 of theGeneral Special Requirements Provider Manual forinformation on obtaining prior authorization.
Non covered services: Weight reduction with exception of those requiring
PA. EXCEPTION: Orlistat (Xenical®) and sibutramine
(Meridia®) will be covered with PA. Individualswith a body mass index (BMI) greater than 30 orgreater than 27 with comorbidity may be eligible toreceive orlistat or sibutramine with PA.
Not explicitly mentioned.
28
KENTUCKYDepartment for Medicaid Services
Cabinet for Health and Family Services
NutritionalAssessment/Counseling90,91
Pharmaceutical Therapy92 Bariatric Surgery93
Adults:CPT codes 96150, 96151-96153, and97802-97804 are covered according to theKY Medicaid fee schedule.
CPT Codes: 96150-96153, 97802-97804
EPSDT:Obesity services outside of mandatedEPSDT services are not explicitlymentioned.
The following is a list of non-covered (i.e.,excluded from the Medicaid benefit) drugsand/or categories: Agents used for anorexia, weight gain
or weight loss.
Bariatric Surgery for the treatment of morbid obesity is considered medically necessary when pre-authorized with the following criteria met:1. Presence of morbid obesity, defined as either: Body mass index (BMI)* exceeding 40; OR, BMIgreater than 35 in conjunction with ANY of the following severe co-morbities: Coronary heart disease;OR, Type 2 diabetes mellitus; OR, Clinically significant obstructive sleep apnea ( i.e., member meets thecriteria for treatment of obstructive sleep apnea; OR, Medically refractory hypertension (blood pressuregreater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);AND;2. Member has completed growth (18 years of age or documentation of completion of bone growth);AND;3. The member must concurrently participate in an organized multidisciplinary surgical preparatoryregimen coordinated by a qualified bariatric surgeon in order to improve surgical outcomes, reduce thepotential for surgical complications, and establish the member's ability to comply with post-operativemedical care and dietary restrictions.AND;4. Member has participated in a physician-supervised nutrition and exercise program (including a lowcalorie diet, increased physical activity, and behavioral modification). This physician-supervised nutritionand exercise program must meet ALL of the following criteria: Participation in nutrition and exerciseprogram must be supervised and monitored by a physician; AND, Nutrition and exercise program mustbe 6 months or longer in duration; AND, Nutrition and exercise program must occur within the two yearsprior to surgery; AND, Participation in physician-supervised nutrition and exercise program must bedocumented in the medical record by an attending physician who does not perform bariatric surgery.Note: A physician’s summary letter is not sufficient documentation. Programs such as WeightWatchers®, Jenny Craig® and Optifast® are acceptable alternatives if done in conjunction with physiciansupervision and detailed documentation of participation is available for review. However, physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meetthis requirement.AND;5. Mental health evaluation by a psychiatrist or psychologist to determine any contraindications as listedbelow, mental competency and understanding of the nature, extent and possible complications of thesurgery and ability to sustain dietary behavioral modifications needed to ensure a successful outcome ofsurgery. Contraindicated diagnoses are: active drug abuse, active suicidal ideation, borderline personalitydisorder, schizophrenia, psychotic disorder, uncontrolled depression, defined non-compliance withprevious medical care
Procedures CoveredOnly the following surgical procedures are covered: Gastric segmentation along its vertical axis with a Roux-en-Y bypass with distal anastomosis placed
in the jejunum Laparoscopic adjustable silicone gastric banding Biliopancreatic Diversion with Duodenal Switch Laparoscopic or open sleeve gastrectomy; laparoscopic longitudinal gastrectomy
29
LOUISIANAMedicaid (Health Services Financing)
Office of Management and Finance, Department of Health and Hospitals
Nutritional Assessment/Counseling94,95 Pharmaceutical Therapy96 Bariatric Surgery97Adults:Not explicitly mentioned in provider manual;however, some services are reimbursable underphysician fee schedule.
CPT Codes: 96150-96155 and 97802-97804
EPSDT:Obesity services outside of mandated EPSDTservices are not explicitly mentioned.
Agents when used for anorexia, weight loss orweight gain (Orlistat only) are not covered byLouisiana Medicaid unless they are covered byMedicare Part B or Part D.
Louisiana Medicaid covers bariatric or weight loss surgery as an optiononly after a comprehensive and sustained program of diet and exercisewith or without pharmacologic measures has been unsuccessful overtime. Bariatric surgery may consist of open or laparoscopic proceduresthat revise the gastro-intestinal anatomy to restrict the size of thestomach and/or reduce absorption of nutrients.
Prior AuthorizationSurgeons who perform bariatric surgery must obtain prior authorizationthrough the fiscal intermediary’s Prior Authorization (PA) Unit. The PArequest shall include a thorough multidisciplinary evaluation within theprevious 12 months. A physician letter documenting recipientqualifications and medical necessity must accompany the PA requestand must include confirmatory evidence of co-morbid condition(s).Photographs must be submitted with the request for consideration ofbariatric surgery.
Eligibility CriteriaAll of the following criteria must be met by candidates for bariatricsurgery: Be a minimum of 16 years of age, Have a documented weight in the morbidly obese range as defined
by a body mass index greater than 40, Have at least three failed efforts at medical therapy and is
experiencing the complications of extreme obesity, Have current obesity-related medical conditions which are
classified as being very high risk for morbidity and mortality, Not have a major psychiatric diagnosis as the cause of the obesity
or which will act as a deterrent to successful treatment as evidencedby the results of a psycho-social evaluation,
Not be currently abusing alcohol or other substances, and Be capable of complying with the modified food intake regimen
and follow-up program which will come after surgery.
30
MAINEOffice of MaineCare Services
Department of Health and Human Services
Nutritional Assessment/Counseling98,99 Pharmaceutical Therapy100 Bariatric Surgery101Adults:Not explicitly mentioned in provider manual; however,some services are reimbursable under physician feeschedule.
CPT Codes: 99401-99403 and 97802-97804
EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned.
Weight loss drugs and nutritional support productsprescribed for managing body weight or enhancingnutrient intake when the member is able to eatconventional foods are non-covered services byMaineCare.
Gastric bypass, gastroplasty and adjustable gastricbanding are among the restricted services covered byMaineCare.
Reimbursement will be made to the physician, hospital orother health care provider for services related to gastricbypass, gastroplasty surgery or adjustable gastric bandingonly when prior approval has been granted by theDepartment. The request for prior authorization must besubmitted by the surgeon who will be performing thesurgery.
For Members age twenty-one (21) years and younger, thesurgery must also be recommended by all of thefollowing, with documentation submitted with the priorapproval request:a. a primary care provider;b. an endocrinologist;c. second surgeon not affiliated with the first surgeon’s
practices; andd. a licensed mental health professional specializing in
children’s mental health
31
MARYLANDMedical Programs, Department of Health and Mental Hygiene
Nutritional Assessment/Counseling102 Pharmaceutical Therapy103 Bariatric Surgery104Adults:Excluded services include: Diet and exercise programs for weight loss except
when medically necessary.
CPT Codes: HealthChoice is a series of managed careplans with individual fee schedules (individuals shouldcontact their respective MCO provider for coveragedetails).
EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned.
Limitations: neither the State nor the MCO cover thefollowing: Prescriptions or injections for central nervous
system stimulants and anorectic agents when usedfor controlling weight.
Bariatric surgery appears to be covered by inclusion ofCPT/HCPCS-II codes 43644-43645, 43770-43774,43842-43843, 43845, 43846-43847, and 43848 in the2011 Fee Schedule.
Other guidelines for gastric procedures were not found.
32
MASSACHUSETTSMassHealth, Office of Health and Human Services
Nutritional Assessment/Counseling105,106,107
Pharmaceutical Therapy108 Bariatric Surgery109
Adults:Does not explicitly mention.
CPT Codes: None
EPSDT:Medical nutrition therapy/diabetes self-management training are among theexceptions of services requiring referrals.
MassHealth does not explicitly say thatnutrition counseling is paid for, with theexception of individuals receiving prenatalcare or adult day care.
MassHealth does not pay for any prescription, over-the-counter drug or therapy that is used for obesitymanagement.
MassHealth bases its determination of medical necessity for bariatricsurgery on a combination of clinical data and presence of indicatorsthat would affect the relative risks and benefits of the procedure. It isdetermined on an individual, case-by-case basis, in accordance with130 CMR 450.204, when needed to either alleviate or correct medicalproblems caused by severe obesity. These guidelines apply to Roux-en-Y gastric bypass surgery. Requests for other forms of bariatricsurgery will require exceptional circumstances and additionaldocumentation, depending on the case.
These criteria include, but are not limited to, the following.1. The surgery will be performed under the guidance of a
multidisciplinary team particularly experienced in the performanceof bariatric surgery and the pre- and post- operative managementof bariatric surgery patients.
2. The surgery will be performed in a facility equipped to properlycare for bariatric surgery patients.
3. The member has a body mass index (BMI) greater than 40 or aBMI greater than or equal to 35 with significant co-morbidconditions, for example degenerative joint disease, circulatory andrespiratory insufficiency, arteriosclerosis, hypertension, diabetesmellitus, obstructive sleep apnea, or dyslipidemia.
4. The member has been severely obese for at least five years.5. The provider has ruled out metabolic causes of the member’s
obesity.6. The member is at least 18 years of age.7. The member is well informed of the risks of surgery.8. The member is under a physician’s supervision for the treatment
of obesity.9. The member has satisfactorily completed the pre-operative care
plan.10. There is no evidence of active substance abuse.11. Any history of binge eating disorder has been documented and
discussed.
33
MICHIGANDepartment of Community Health
Nutritional Assessment/Counseling110,111 Pharmaceutical Therapy112 Bariatric Surgery113Adults: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 prior authorization and document that otherweight reduction efforts and/or additional treatment ofconservative measures to control weight and manage thecomplications have failed.
The request for prior authorization must include:1. The medical history;2. Past and current treatment and results;3. Complications encountered;4. All weight control methods that have been tried and
failed; and5. Expected benefits or prognosis for the method being
requested.
CPT Codes: None
EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned.
Prior authorization is required for prescription weightloss drugs. Depending on the specific drug beingprescribed, additional medical documentation may berequired.
The most common categories requiring additionaldocumentation are:1. Current medical status, including nutritional or
dietetic assessment.2. Current therapy for all medical conditions, including
obesity.3. Documentation of specific treatments, including
medications.4. Current accurate Body Mass Index (BMI), height,
and weight measurements.5. Confirmation that there are no medical
6. Details of previous weight loss attempts and clinicalreason for failure (at least two failed,physician supervised, attempts are required).
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 PriorAuthorization and document that other weight reductionefforts and/or additional treatment of conservativemeasures to control weight and manage the complicationshave failed.
The request for prior authorization must include:1. The medical history;2. Past and current treatment and results;3. Complications encountered;4. All weight control methods that have been tried and
failed; and5. 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 in addition to the following guidelines.
34
MINNESOTADepartment of Human Services
Nutritional Assessment/Counseling114,115 Pharmaceutical Therapy116 Bariatric Surgery117Adults:MHCP covers physician visits, medical nutritional therapy, mentalhealth services, and laboratory work provided for weightmanagement. Services must be billed by enrolled providers on acomponent basis with current CPT codes. Authorization may berequired for mental health services. Refer to MHCP Mental HealthService policy for requirements.
MHCP reimburses Dietician or Nutritionist services listed onlywhen prescribed by a physician and provided in an office oroutpatient setting. MNT and DSMT are separate benefits and maynot be billed for the same date of service. Payment for medicalnutritional therapy is limited to various codes.
The follow services are not covered under the weight loss servicepolicy: Weight loss services on a program basis Nutritional supplements or foods for the purpose of weight
reduction Exercise classes Health club memberships Instructional materials and books Motivational classes Counseling or weight loss services provided by persons who
are not MHCP providers Counseling that is part of the physician's covered services and
for which payment has already been made Nutritional counseling for diabetic education when it is part of
a diabetic education program (see Diabetic Education section)
EPSDT:Obesity services outside of mandated EPSDT services are notexplicitly mentioned.
Drugs that are used for weight loss are notcovered.
The following criteria apply only to MHCP enrolleesages 18 and older.
All four of the criteria listed below must be met in orderto authorize bariatric surgery. Patients not meeting thecriteria, who have one or more immediate, life-threatening comorbidities, will be considered forapproval on a case-by-case basis when the recipient isclinically obese with one of the following: BMI of 40 or higher BMI of 35-40 with one or more of the following
comorbid conditions: Severe cardiac disease(coronary artery disease, pulmonary hypertension,congestive heart failure, or cardiomyopathy)
Type 2 diabetes Obstructive sleep apnea and other respiratory disease
Pseudo-tumor cerebri Gastroesophageal reflux disease Hypertension Hyperlipidemia Severe joint or disc disease that interferes with daily
functioning
The BMI level qualifying the patient for surgery (> 40 or> 35 with one of the above comorbidities) must be of atleast two years duration. A patient’s required attempt(s)to lose weight may cause their BMI to fluctuate aroundthe discrete required 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.
Similar criteria apply for adolescent bariatric surgery.
35
MISSISSIPPIDivision of Medicaid
Nutritional Assessment/Counseling118,119 Pharmaceutical Therapy120 Bariatric Surgery121Adults:Not explicitly mentioned in provider manual; however,some services are reimbursable under physician feeschedule.
All counseling is explicitly NOT covered in the feeschedule except for 99078 (group counseling for patientswith symptoms / illnesses) which is covered as part of abundled service.
CPT Codes: 99078 (bundled service)
EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned.
Mississippi Medicaid pharmacy program excludes drugswhen used for anorexia, weight loss or weight gain.
Beneficiaries, under the age of twenty-one (21) however,have unlimited prescription drug coverage within theparameters of the drug program. No limitations, otherthan prior authorization requirements for specific drugsand/or classes of drugs listed in the comprehensive plan,shall exist.
No payment may be made under the Medicaid programfor gastric surgery (any technique or procedure) for thetreatment of obesity or weight control, regardless ofmedical necessity.
36
MISSOURIMO HealthNet Division, Department of Social Services
EPSDT:In Missouri, this program is called "Healthy Childrenand Youth." The list provided are services available forchildren age 0 through 20 years and do not explicitlystate that they are related to weight or nutrition, butamong them are: physical therapy psychology counseling case management services other medically necessary services screening services including
o physical developmento anticipatory guidance
Not explicitly mentioned. Obesity treatment:Procedures for bariatric surgery (43770) gastroplasty(43843), unlisted laproscopy procedure, stomach(43659) and gastric bypass for morbid obesity (43846,43847 and 43848) are covered surgical procedures whenperformed as treatment for a concurrent or complicatingmedical condition and must be prior authorized. A PriorAuthorization Request form and supportingdocumentation, if appropriate, must be submitted to thefiscal agent, Infocrossing Healthcare Services, forprocessing. Refer to Section 8 for additional information.Bariatric surgery procedure codes 43771, 43772, 43773and 43774 do not require prior authorization.When billing MO HealthNet for any services related toobesity, the primary diagnosis must be for a concurrent orcomplicating medical condition. The claim should reflectobesity as a secondary diagnosis.
Morbid obesity treatment:The following codes for bariatric surgery, gastric bypass,gastroplasty, and laparoscopy are covered codes by MHDfor patients with a BMI of greater than 40 and a co-morbid condition(s): 43644, 43645, 43659, 43770,43843, 43846, 43847, 43848. These services must beprior authorized. Refer to section 8 of the physician'smanual to review MHD's prior authorization policy.
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
Nutritional Assessment/Counseling125,126 Pharmaceutical Therapy127 Bariatric Surgery128Adults:Weight Reduction: Physicians and mid-levelpractitioners who counsel and monitor clients on weightreduction programs can be paid for those services. Ifmedical necessity is documented, Medicaid will alsocover lab work. Similar services provided bynutritionists are not covered for adults.
EPSDT:The Montana Medicaid nutrition services programcovers the following nutrition services for childrenthrough age 20 through the EPSDT program: Nutrition screening to collect subjective and
objective nutritional and dietary data about a child. Nutrition counseling with a child or a responsible
caregiver, to explain the nutrition assessment and toimplement a plan of nutrition care.
Nutrition assessment for evaluation of a child’snutritional problems, and design a plan to prevent,improve, or resolve identified nutritional problems,based upon the health objectives, resources, andcapacity of the child.
Nutrition counseling with or for health professionals,researching, or resolving special nutrition problemsor referring a child to other services, pertaining to thenutritional needs of the child.
Nutritional education for routine education fornormal nutritional needs.
The Montana Medicaid prescription drug program doesnot reimburse or pay for drugs prescribed for weight loss.
Medicaid does not cover gastric bypass surgery.
38
NEBRASKADepartment of Health & Human Services
Nutritional Assessment/Counseling129,130 Pharmaceutical Therapy131 Bariatric Surgery132Adults: Not explicitly mentioned.
None of the CPT Codes are covered according to thephysicians’ services fee schedule.
CPT Codes: None
EPSDT: Obesity services outside of mandated EPSDTservices are not explicitly mentioned.
Non-Covered ServicesPayment by NMAP will not be approved for: Drugs or items prescribed or recommended for
weight control and/or appetite suppression.
Coverage is restricted to recipients with the followingindicators: BMI 40 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 this surgical procedure.
Surgical procedures deemed experimental, not wellestablished or not approved by Medicare or Medicaid arenot covered and will not be reimbursed for payment.Below is a list of definitive non-covered services whichinclude:1. Intestinal bypass surgery for treatment of obesity.2. Gastric balloon for the treatment of obesity.3. Surgical procedures to control obesity other than
gastric bypass for morbid obesity with significantcomorbidities.
39
NEVADADepartment of Health and Human Services, Division of Health Care Financing & Policy
Nutritional Assessment/Counseling133,134 Pharmaceutical Therapy135 Bariatric Surgery136Adults:Medicaid will not cover services such as routinephysical exams for adults or weight control programs.Nevada Medicaid reimburses for preventive medicineservices (obesity screening and counseling) for womenas recommended by the U. S. Preventive Services TaskForce (USPSTF) A and B Recommendations.
CPT Codes: 96150-96154, 99401, 98960, and 98961
EPSDT:Nevada Medicaid reimburses for preventive medicineservices as recommended by the U. S. PreventiveServices Task Force (USPSTF) A and BRecommendations. The USPSTF recommends suchscreening and intensive counseling for children 6 yearsand older and offer them or refer them tocomprehensive, intensive behavioral interventions topromote improvement in weight status.
The Nevada Medicaid Drug Rebate program will notreimburse for any agents used for weight loss.
Requires Prior Authorization and documentation ofmedical necessity; gastric bypass surgery is a covered forrecipients with severe and resistant morbid obesity inwhom efforts at medically supervised weight reductiontherapy have failed and who are disabled from thecomplications of obesity.
Gastric bypass surgical procedure is indicated forrecipients between the ages of 21 and 55 years withmorbid obesity (potential candidates older than age 55will be reviewed on a case by case basis).
Coverage is restricted to recipients with the followingindicators: BMI 40 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 this surgical procedure No coverage will be provided for pregnant women,
women less than six months postpartum, or womenwho plan to conceive in a time frame less than 18 to24 months post gastric bypass surgery
3 year documentation of medically supervisedweight loss and weight loss therapy
40
NEW HAMPSHIREDepartment of Health and Human Services
Nutritional Assessment/Counseling137,138 Pharmaceutical Therapy139 Bariatric Surgery140Adults:Non-covered services include dietary servicesand/or exercise programs for the treatment ofobesity.
CPT Codes: 96150-96154, 99401, 98960-98961
EPSDT:Obesity services outside of mandated EPSDTservices are not explicitly mentioned.
Requires clinical prior authorization for anti-obesity medication.
Requires Prior Authorization and medical necessity
Roux-en-Y Gastric Bypass surgery may be covered for non-cosmeticindications for Medicaid recipients 18 years of age or older, but less than 65,when all of the following criteria are met: The recipient has lost and maintained the loss of at 15% of body weight
prior to scheduling surgery Body Mass Index (BMI) must be between 35 and 40 with life
threatening co-morbidities of cardio-pulmonary problems,cardiovascular disease, uncontrolled severe Diabetes Mellitus, ormedically refractory hypertension. Inadequate treatment of a co-morbidcondition should not be used as an indication for Roux-en-Y GastricBypass surgery.
BMI > for greater than 5 years (unspecified BMI level to qualify) The recipient has participated in a physician-supervised/directed
program including nutritional counseling, a low calorie diet, increasedphysical activity, and behavioral modification. This needs to bedocumented in the recipient’s medical record. The nutrition and exerciseprogram must be supervised and monitored by a physician. It must alsobe for a minimum cumulative total of 6 months or longer in duration andoccur within 2 years of surgery, with participation in one program of atleast 3 consecutive months. Diet plans of Jenny Craig, Weight Watchersetc. are not considered physician directed/monitored nutritional weightloss programs. Physician visits consisting of only pharmacologicalmanagement are also not considered toward this goal.
The recipient has the ability to adhere to lifestyle changes/modifications. The recipient does not have a specific correctable cause for the obesity,
such as an endocrine metabolic disorder. A comprehensive psychological evaluation has been done to rule out an
undiagnosed underlying psychological disorder, to determine therecipient is able to understand, tolerate and comply with all phases ofcare and is committed to long-term follow-up requirements Therecipient has had previous conservative weight reduction attemptswithout long-term weight reduction.
The recipient has attended AT LEAST three gastric bypass seminars athis/her own expense, and passed the tests given.
EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned.
Lipase inhibitors, used in the treatment of obesity, requireprior authorization as follows:1. The provider shall telephone the pharmacy prior
authorization agent, using the toll-free telephonenumber supplied by the Division. Pharmacy priorauthorization is available 24 hours a day, seven daysa week. The pharmacy prior authorization agentreviews the information provided and automaticallyprior-authorizes a 30-day supply. Subsequentauthorizations are based on criteria established bythe New Jersey Drug Utilization Review Board, asspecified below.
2. The lipase inhibitors will be provided for an initial30-day period. A prior authorization will be issuedwithout clinical criteria for an initial prescription fora maximum 30-day supply. During this initial 30-dayperiod, the pharmacy prior authorization agent willcontact the physician to request justification forcontinuing the use of the lipase inhibitor. Ifjustification is received by the pharmacy priorauthorization agent, the lipase inhibitor will be priorauthorized for an additional 30-day supply. Afterthese two 30-day periods, any subsequent provisionof lipase inhibitors shall not be dispensed withoutprior authorization. Such subsequent priorauthorizations for lipase inhibitors shall be limited to90-day supply.
Surgical operations, procedures or treatment of obesity,shall not be covered, except when specifically approvedby the HMO.
Appears to be covered in DRG manual, pre-approvalcriteria not specified.
42
NEWMEXICOHuman Services Department
Nutritional Assessment/Counseling145,146 Pharmaceutical Therapy147 Bariatric Surgery148Adults:New Mexico Medicaid does not provide coverage forthe following:1. Services not considered medically necessary for the
condition of the recipient;2. Dietary counseling for the sole purpose of weight
loss;3. Weight control and weight management programs;
andCommercial dietary supplements or replacementproducts marketed for the primary purpose of weightloss and weight management.
CPT Codes: 96150-96151, 96153-96154, 97802-97804
EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned.
New Mexico Medicaid does not cover weight loss orweight controlling drugs.
New Mexico Medical Assistance Division does not coverbariatric or other weight reduction surgeries orprocedures.
EPSDT:Services include screening of children and youth fornutritional risk at each visit. Nutritional risk includesoverweight and hyperlipidemia, or inappropriate feedingpractices. Each visit should also include an evaluation ofgrowth, dietary practices, a general health history, thephysical exam, and laboratory tests.
Adolescents receive an annual screen for eatingdisorders and obesity by determining weight, stature andBMI, and asking about body image and dieting patterns.
EPSDT providers should be alert for nutrition problems,such as obesity (and its complications such as type IIdiabetes and hyperlipidemia).
Coverage for amphetamine and amphetamine-likesubstances is only available when used in outpatienttreatment of conditions other than obesity or weightreduction. No payment will be made for any drug whichhas weight reduction as its sole clinical use.
Gastric bypass does not require prior approval but shouldbe a treatment of f last resort to control obesity. It iscovered under the following circumstances:1. It is an integral and necessary part of a course of
treatment for an illness;2. The obesity was created by or is aggravating or
creating pathological disorders; and3. Regular medical treatment including endocrine,
nutritional psychiatric, and counseling services, asappropriate, have been provided to the patient for aperiod of 12-24 months and regular weighing ofpatient has indicated insignificant weight loss.
As of January 1, 2011, partial gastrectomy (sleevereduction of the stomach) procedures, when accompaniedby a primary diagnosis of obesity, unspecified, morbidobesity or overweight, is also covered.
44
NORTH CAROLINADepartment of Health and Social Services
EPSDT:The Child Service Coordination program informsfamilies of the importance of preventive health care andassists them access these services, including nutritionservices.
Dietary evaluation and counseling are provided by aqualified nutritionist to Medicaid eligible childrenthrough age 20 identified as having risk conditions bytheir health care provider, include by are not limited to:1. Nutrition assessment;2. Development of an individualized care plan;3. Diet therapy; and4. Counseling, education about needed nutrition habits
and skills, and follow-up.
North Carolina does not cover drugs used for weight loss. If general and specific criteria are met, the followingservices are covered:1. Roux-en-Y gastric bypass;2. Adjustable gastric banding;3. Biliopancreatic diversion with or without duodenal
switch; and4. Revision of bariatric surgery.
General criteria require that:1. The procedure is individualized, specific, and
consistent with symptoms or confirmed diagnosis ofthe illness, and not in excess of the recipient’s needs;
2. The procedure can be safely furnished, and noequally effective and more conservative or lessexpensive treatment is available statewide; and
3. The procedure is furnished in a manner no primarilyintended for the convenience of the recipient.
Specific criteria require that:1. The recipient is at least 18 years old;2. The recipient has a BMI > 40 or a BMI > 35 with at
least one comorbidity complicated by clinicallysevere or morbid obesity;
3. Clinical health records document all of thefollowing:a. Clinically severe or morbid obesity has been
present for at least 2 years;b. The recipient has attempted weight loss over this
period without sustained results; andc. The recipient has no correctable cause for the
obesity, such as an endocrine disorder.4. The recipient undergo a multidisciplinary pre-
surgical preparatory regimen; and5. The recipient undergoes a psychological and
Adults:Nutritional services are allowed up to four (4) visits percalendar year without prior authorization.
North Dakota Medicaid does not pay for:1. Exercise class;2. Nutritional supplements for the purpose of weight
reduction;3. Instruction materials and books; or4. Diet pills with the exception of Xenical
CPT Codes: None
EPSDT:Coverage includes comprehensive health anddevelopmental history as well as health education andanticipatory guidance.
Health education is a required component of EPSDTscreening services and includes anticipatory guidance.Health education and counseling for parents (orguardians) and children is required and is designed toassist in understanding what to expect in terms of thechild’s development and to provide information aboutthe benefits of healthy lifestyles and practices.
Orlistat is covered by prior authorization with dieticianevaluation, for recipients with BMI > 40. Updates onprogress are required semi-annually and coverage will beterminated if no progress is shown (specifically 5%weight loss in six months). Coverage is also terminated ifBMI 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 with
presence of serious comorbidity);2. Failure of obesity management programs to achieve
weight 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)years is required. Chart notes for the last three (3)years from a PCP plus documentation ofparticipation in a supervised program need to besubmitted;
3. Presence of severe disease condition(s) due toobesity that are not adequately controlled withcurrent medical treatment;
4. Active participation in their medical management;5. A formal psychiatric evaluation performed by a
specialist (psychiatrist/psychologist) demonstratingemotional stability over the past year; and
6. Documentation from surgeon stating the patient isable to tolerate the procedure and is willing tocomply postoperatively both physical andpsychologically.
46
OHIODepartment of Job & Family Services
Nutritional Assessment/Counseling167,168,169,170
Pharmaceutical Therapy171 Bariatric Surgery172
Adults:Medicaid-covered preventive medicine services include:1. Screening and counseling for obesity provided
during an evaluation and management or preventivemedicine visit; and
2. Medical nutritional therapy.
CPT Codes: 99402-99404, 97802-97804, S9470, S9452
EPSDT:Nutritional screenings include questions regardingdietary practices, measurements of height and weight,laboratory testing (if medically indicated), and acomplete physical examination.
Health education must include counseling, anticipatoryguidance, and risk-factor related intervention. Theeducation and guidance should provide information onthe benefits of healthy lifestyles and disease prevention.When EPSDT screening indicates need for furtherevaluation of an individual’s health, the provider shall,without delay, make a referral for evaluation, diagnosis,and/or treatment.
Ohio Medicaid Pharmacy Program does not cover drugsfor treatment of obesity.
Ohio Medicaid does not cover the treatment of obesity,including but not limited to gastroplasty, gastric stapling,ileo-jejunal shunt, or other gastric restrictive procedures.
Adults:Oklahoma Medicaid pays for six hours of medicallynecessary nutritional counseling per year by alicensed registered dietician. All services must beprescribed by a physician, a physician assistant,advance practice nurse, or nurse midwife and beface to face encounters between a licensedregistered dietician and the member. Services mustbe expressly for diagnosing, treating or preventing,or minimizing the effects of illness. Nutritionalservices for the treatment of obesity are not coveredunless there is documentation that the obesity is acontributing factor in another illness.
CPT Codes: 96150-96155, 97802-97804, 98960-98962, and S9445
EPSDT:Program requires regularly scheduled examinationsand evaluations of the nutritional status of infants,children, and youth. Each visit shall recordmeasurements of height and weight. Beginning atage 4 and with each subsequent visit, a BMI is to becalculated and charted.
Nutritional assessments may include preventivetreatment and follow-up services including dietarycounseling and nutrition education if appropriate.This is accomplished in the basic examinationthrough:
1. Questions about dietary practices;2. Height and weight measurements
Oklahoma Medicaid does not cover drugs usedfor the primary for the treatment of anorexia,weight gain, or obesity.
Oklahoma Medicaid does not cover bariatric surgery for the treatment ofobesity alone. To be eligible for Medicaid reimbursement, providers mustbe nationally certified and all qualifications must be met and approved bythe Oklahoma Health Care Authority (OHCA). Bariatric surgery must becontracted with OHCA.
To be eligible for bariatric surgery, the recipient must:1. Be between 18 and 65 years old;2. Have BMI > 35 and the obese condition must have persisted for at
least five (5) years;3. Be diagnosed with one of the following:
a. Diabetes;b. Degenerative joint disease of major weight bearing joints; orc. A rare comorbid condition for which evidence supports that
bariatric surgery is medically necessary to treat such a conditionand that the benefits of surgery outweigh the risk of surgicalmortality;
4. Have documentation of unsuccessful attempts at weight loss;5. Have absence of other medical conditions that would increase risk of
surgical mortality or morbidity; and6. Not be pregnant or planning to become pregnant in the next two
years.Once OHCA certifies that the member meets the above requirements, thePCP must coordinate a pre-operative assessment and weight loss processincluding:1. Psychological evaluation;2. Surgical and medical evaluation; and3. Member participation in a six (6) month physician-supervised weight
loss program, the member must, within 180 days, lost at least 5% ofmember’s initial body weight.
When all requirements have been met, a prior authorization for surgerymust be obtained. This authorization cannot be requested before theinitial 180-day weight loss program has been completed. If the memberdoes not meet the weight loss requirement in the allotted time, themember will not be approved for surgery and the provider must restart theprior authorization process.
Adults:Oregon Medicaid does not cover weight loss programsincluding, 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 intensivecounseling on nutrition and exercise, provided by healthcare professionals. Intensive counseling is defined asface to face contact more than monthly. Visits are not toexceed more than once per week. Intensive counseling(once every 1-2 weeks) are converted for six (6) months.Intensive counseling may continue for longer than six(6) months as long as there is evidence of continuedweight loss. Maintenance visits are covered no morethan monthly after this intensive counseling period.
EPSDT:Periodic screening exams must include a comprehensivehealth and developmental history, including anassessment of physical development, an assessment ofthe child’s nutritional status, health education, andanticipatory guidance. EPSDT services also include anyinter-periodic encounters with a physician that aremedically necessary by referral.
Weight loss drugs are covered with prior authorizationfor covered diagnoses. Obesity is not a covereddiagnosis. Covered drugs include Xenical (Orlistat) andApidex (Phetermine).
Bariatric surgery is covered with prior authorization. Foreach of these services, the primary care provider mustrefer the patient for evaluation pursuant to the PrioritizedList of Guidelines directed to Director of MedicalAssistance Programs Policy for review and transmittal tothe Medical-Surgical Prior Authorization contractor.
Bariatric surgery for obesity is covered for individuals 18years and older with a BMI > 35 with type II diabetes oranother significant comorbidity or BMI > 40 without asignificant comorbidity. The individual must have noprior history of roux-en-Y gastric bypass or laparoscopicadjustable gastric banding, unless in failure due tocomplications of the original surgery. The individualmust also participate in psychological, medical, surgical,and dietician evaluations. The individual must alsoparticipate in post-surgical evaluations.
EPSDT:Assessments include a comprehensive history andexamination, counseling, anticipatory guidance, riskfactor reduction interventions, age-appropriatenutritional counseling, the calculation of BMI, andordering of appropriate laboratory diagnostic proceduresas recommended by current AAP guidelines.
Childhood nutrition and weight management servicesprovide medically necessary services to recipients under21 years of age who are overweight, obese, orexperiencing weight management problems. Childhoodnutrition and weight management services consist of thefollowing specific services:
1. Initial and re-assessment;2. Individual, family, and group weight
management and nutritional counseling.
Non-compensable services and items include drugs andother items prescribed for obesity, appetite control, orother similar or related habit-altering tendencies.
Non-compensable services include gastroplasty formorbid obesity, gastric stapling, or ileo-jejunal shuntexcept when all other types of treatment for morbidobesity have failed.
Adults:Rhode Island Medicaid does not cover weight losscenters or diet centers.
Nutritional services are covered as delivered by alicensed dietician for certain conditions and as referredby a health plan.
CPT Codes: 97802-97804
EPSDT:Standardized services for evaluation of childdevelopment, including BMI measurement, bloodpressure screening (if at risk), psychological/behavioralcounseling, and age-appropriate anticipatory guidance.
Rhode Island Medicaid covers all types of anorexiantswith prior authorization, but limited to a three-monthsupply.
Rhode Island Medicaid covers the following:1. Gastric bypass, other than with roux-en-Y
gastroenterostomy, for morbid obesity;2. Gastroplasty, any method for morbid obesity; and3. Gastric bypass with roux-en-Y gastroenterostomy
for morbid obesity.
Treatment for morbid obesity is covered when:1. The individual is 50% above or 100 pounds over
their ideal body weight, whichever is greater;2. The duration of obesity exceeds three years (non-
consecutive years are acceptable);3. There is a presence of physical trauma caused by
excess weight, pulmonary and circulatoryinsufficiencies, and/or complications related to thetreatment of conditions such as arteriosclerosis,diabetes, coronary disease, etc; and
4. The patient is between the ages 18 and 60.
A second operation to restore the gastrointestinal tract tonormal is also covered when medically necessary.
The following services will not be covered:1. Procedures performed for cosmetic reasons due to
the weight loss; and2. Insertion and/or removal of the gastric bubble,
including dietary behavioral modification.
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SOUTH CAROLINADepartment of Health and Human Services
Adults:Preventive/Rehabilitative Services for Primary CareEnhancement are provided to support primary medicalcare in patients who exhibit risk factors that directlyimpact their medical status. These services are designedto help the physician maximizing the patient’s treatmentbenefits and outcomes by supplementing routine medicalcare.
This includes:1. Comprehensive assessments/evaluations of client’s
medical, nutritional, or psychological needs byhealth professionals; and
2. Medical nutrition therapy for clients with chronicdisease or other nutritional disorders.
South Carolina Medicaid does not cover weight controlproducts (except for lipase) or nutritional supplements.
CPT Codes: 96150-96154, 99401-99404, 97802
EPSDT:Screening includes a comprehensive health anddevelopmental history and health education withanticipatory guidance. The child’s height and weightshould be obtained and plotted on a graphic recordingsheet to compare them with the child’s age group. Theprovider should also assess the child’s nutritional statusat each screening to include eating habits and generaldiet history.
Coverage for Lipase inhibitors needs prior authorizationwhen prescribed for morbid obesity orhypercholesterolemia. Patients must also be at least 18years of age.
Coverage for Xenical for diagnosis of morbid obesityrequires that the individual:1. Have a diagnosis of obesity in the presence of other
risk factors (e.g., hypertension, diabetes);2. Have an initial BMI > 30; and3. Have reduced his/her caloric diet with nutritional
counseling regarding adherence to dietaryguidelines.
South Carolina Medicaid does not cover intestinal bypasssurgery or gastric balloon for treatment of obesity.
outerwear, and personal comfort or environmentalcontrol equipment, including air conditioners,humidifiers, dehumidifiers, heaters, and furnaces;and
2. Any weight loss program or activity.
CPT Codes: 96150-96154
EPSDT:Obesity services outside of mandated EPSDT servicesare not explicitly mentioned.
Non Covered ServicesThe following are not reimbursable under theDepartment of Social Services PharmacyProgram: Medical supplies, food or nutritional
supplements, delivery charges. Items prescribed for weight control or
appetite suppressants.
Services not covered.In addition to items and services specified as not covered in othersections of this article, the following are examples of items andservices not covered under the medical assistance program: Gastric bypass, gastric stapling, gastroplasty, any similar
surgical procedure, or any weight loss program or activity
However, when weight loss is critical to the treatment of severeco-morbid conditions, cases may be reviewed for medicalnecessity (ARSD 67:16:01:06.02). A prior authorization processis available for severe cases utilizing South Dakota specialistevaluations. This determination may take six months or longer.
Obesity and Gastric ProceduresSevere Co-Morbid Conditions Coverage: Prior authorizationis available for severe cases in which:1) Individual is severely obese with a BMI > 402) Significant interference with activities of daily living3) Documented failure of any sustained weight loss under
medical supervision4) Medically appropriate for the individual to have such surgery5) The surgery has been prior authorized by the department6) There is medical documentation of the following:
a. history of pain and limitation of motion in any weightbearing joint or the lumbosacral spine; or
b. hypertension with diastolic blood pressure persistently >100mmHg; or
c. Congestive heart failure manifested by past evidence ofvascular congestion such as heptomgaly, peripheral orpulmonary edema; or
d. Chronic venous insufficiency with superficial varicositiesin a lower extremity with pain on weight bearing andpersistent edema; or
e. Respiratory insufficiency or hypoxia at rest.
53
TENNESSEETENNCare
Nutritional Assessment/Counseling215,216 Pharmaceutical Therapy217 Bariatric Surgery218Adults:Services, products, and supplies that are specifically excludedfrom coverage under the TennCare program. Weight loss orweight gain and physical fitness programs including, but notlimited to:
1. Dietary programs of weight loss programs, including,but not limited to, Optifast, Nutrisystem, and othersimilar programs or exercise programs
2. Food supplements will not be authorized for use inweight loss programs or for weight gain
3. Health clubs, membership fees (e.g., YMCA)4. Marathons, activity and entry fees5. Swimming pools
CPT Codes: TennCare is a series of managed care plans withindividual fee schedules (individuals should contact theirrespective MCO provider).
EPSDT:Must include a comprehensive health (physical and mental) anddevelopmental history in addition to health education andanticipatory guidance.
Assessment of Nutritional Status accomplished during theexamination through:
1. Questions about dietary practices to identify unusualeating habits or diets which are deficient or excessive inone or more nutrients
2. Accurate measurements of height and weight3. Cholesterol screen for children over 1 year of age,
especially if family history of heart disease and/orhypertension and stroke
4. Determining quality and quantity of individual diets5. Preventive, treatment and follow-up services, including
dietary counseling and nutrition education
Through the use of a formulary, the followingdrugs or classes of drugs, or their medical uses,shall be excluded from coverage or otherwiserestricted by TennCare as described in Section1927 of the Social Security Act [42 U.S.C.§1396r-8]:1. Agents for 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.
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TEXASHealth and Human Services Commission
Nutritional Assessment/Counseling219,220,221,222 Pharmaceutical Therapy223 Bariatric Surgery224,225Adults:Texas Medicaid Wellness ProgramHigh-cost/high-risk fee-for-service and managed care clients may be eligible toreceive targeted care management services through the Texas MedicaidWellness Program. Clients who have a body mass index (BMI) above 25 willreceive vouchers for a weight loss program.Weight Watchers is available through the Wellness Program for Medicaidclients who are 18 years of age and older, and who have a body mass index(BMI) of 25 or greater and who have an interest in losing weight. If the clientmeets the criteria for the Weight Watchers benefit but is not currentlyparticipating in the Wellness Program, providers may refer Medicaid fee-for-service and PCCM clients to the Wellness Program. Clients will be contactedby a community-based nurse and a dietician to determine whether they meetprogram qualifications and whether the program is a good fit for them. As partof the Weight Watchers benefit, qualifying clients will receive ongoing weightloss support and 10 Weight Watchers vouchers. The vouchers can be redeemedat participating Weight Watchers locations.For more information, providers can e-mail Dr. Esteban Lopez, programdirector and medical director, Texas Medicaid Wellness Program, [email protected].
CPT Codes: 99078
EPSDT:Services, Benefits, and LimitationsMedical nutrition therapy (assessment, reassessment, and intervention) andmedical nutrition counseling may be beneficial for treating, preventing, orminimizing the effects of illness, injuries, or other impairments. A casemanager, school counselor, or school nurse may refer a client for medicalnutrition counseling services.Medical nutrition counseling services are a benefit when all of the followingcriteria are met: The client is 20 years of age or younger; The client is eligiblefor CCP; The services are prescribed by a physician; The services areperformed by a Medicaid-enrolled licensed dietitian; Clinical documentationsupports medical necessity and medical appropriateness; FFP is availableMedical nutrition therapy and nutrition counseling may be consideredbeneficial for disease states for which dietary adjustment has a therapeutic role.Such disease states include, but are not limited to, the following conditions:
a. Abnormal weight gain
Exclusions: Medicaid may deny a request if it determinesthe drug is included in one or more of the following classes:1) Amphetamines, when used for weight loss, and
obesity control drugs.
Bariatric surgery is considered medically necessarywhen used as a means to treat covered medicalconditions that are caused or significantly worsenedby the client’s obesity in cases where thosecomorbid conditions cannot be adequately treatedby standard measures unless significant weightreduction takes place.
Prior authorization is required for those eligible formedically necessary bariatric surgery.
Bariatric surgery is not a benefit when the primarypurpose of the surgery is any of the following:
• For weight loss for its own sake• For cosmetic purposes• For reasons of psychological dissatisfaction withpersonal body image• For the client’s or provider’s convenience orpreference
EPSDT:A comprehensive history, obtained from the parent orother responsible adult who is familiar with the child'shistory, should include the following type of history: Nutritional history and status by asking questions
about dietary practices to identify unusual eatinghabits, such as pica or extended use of bottlefeedings, or diets which are deficient or excessive inone or more nutrients.
Health education is a required component of screeningservices and includes anticipatory guidance. Providersare instructed to provide: Health education and counseling to both parents (or
guardians) and children Health education and counseling information about
understanding what to expect in terms of the child'sdevelopment and techniques to enhance a child’sdevelopment
Benefits of healthy lifestyles and practices Nutrition counseling
Non-covered Drugs and ServicesOnly drugs and services described previously as coveredare reimbursable by Medicaid. This chapter summarizesthose products and services which are not covered, andtheir exceptions, if any.
Non-covered drugs include: Agents when used for anorexia, weight loss or
weight gain.
Prior authorization for Medicaid payment of obesitysurgery is required.
EPSDT:Physicians are instructed to calculate child’s BMI, BMIpercentile, and to plot on CDC growth charts. They areinstructed to share this information with families frombirth to 10 years of age. From 10-20 the same procedureis used but the information is to be shared with theadolescent as well as the family. Nutrition and physicalactivity anticipatory guidance is NOT routine and is onlyprovided indicated by risk assessment.
The following drugs/drug classes are not covered throughthe pharmacy benefit: Weight loss drugs
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 Board concerns regarding safety andefficacy 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 index
is 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
EPSDT:In addition, the height (or length) and weight of the childmust be measured. When examining a child two (2)years of age and younger, the provider must measure thechild’s occipital-frontal circumference. Allmeasurements must be plotted on age-appropriate,standardized growth grids and evaluated.
Evaluation of growth and laboratory measures is usefulfor assessing nutritional status. Assessing eating habitsin relationship to developmental stage is also important.If dietary or nutritional problems are identified, areferral to the appropriate professional should be made.
Prior-Authorization for anti-obesity drugs requires thatcandidate meet the following criteria:
BMI requirements Age restrictions Written Documentation Initial Request documentation Agreement to limited-time authorization
Elective surgery, as defined by the Virginia MedicalAssistance Program, is surgery that is not medicallynecessary to restore or materially improve a bodyfunction. This includes surgery for conditions such asmorbid obesity, virginal breast hypertrophy, andprocedures that might be considered cosmetic.
Effective April 1, 2012, regardless of the dates of service,the provider must submit service authorization requeststo KePRO, DMAS’ Service Authorization contractor.Requests may be submitted through direct data entry,telephone, facsimile or US mail. The inpatienthospitalization services must be authorized separatelyfrom the physician’s service authorization by KePRO.
If the member is enrolled in MEDALLION, the orderingphysician must be the MEDALLION primary carephysician (PCP), and there must be a referral for theservice from the MEDALLION PCP. This type ofsurgery may be covered only when all other treatment hasfailed. Service authorization must be obtained.
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WASHINGTONDepartment of Social and Health Services
NutritionalAssessment/Counseling241,242,243
Pharmaceutical Therapy244 Bariatric Surgery245
Adults:HRSA covers medical nutrition therapy whenmedically necessary. Obesity and bariatricsurgery patients are among the list of medicalconditions that can be referred to a certifieddietitian include, but are not limited to.
CPT Codes: 99401, 97802-97804, 99078
EPSDT:Obesity services outside of mandated EPSDTservices are not explicitly mentioned.
HRSA does not cover drugs prescribed for weight lossor gain under the Prescription Drug Program.
Bariatric surgery must be performed in an agency approved hospital andrequires prior authorization.
The Agency covers medically necessary bariatric surgery for clients ages21 to 59 in an approved hospital with a bariatric surgery program inaccordance with WAC 182-531-1600. Prior authorization is required. Tobegin the authorization process, providers should fax the Agency acompleted “Bariatric Surgery Request” form, 13-785.
The Agency covers medically necessary bariatric surgery for clients ages18-20: For the laparoscopic gastric band procedure (CPT code 43770); When prior authorized; When performed in an approved hospital with a bariatric surgery
program; and In accordance with WAC 182-531-1600.
Bariatric Case Management FeeThe Agency may authorize up to 34 units of a bariatric case managementfee as part of the Stage II bariatric surgery approval. One unit of procedurecode G9012 = 15 minutes of service. Prior authorization is required.This fee is given to the primary care provider or bariatric surgeonperforming the services required for Bariatric Surgery Stage II. Thisincludes overseeing weight loss and coordinating and tracking all thenecessary referrals, which consist of a psychological evaluation, nutritionalcounseling, and required medical consultations as requested by the Agency.Clients enrolled in a managed care organization (MCO) are eligible forbariatric surgery under fee-for-service when prior authorized. Clientsenrolled in an MCO who have had their surgery prior authorized by theAgency and who have complications following bariatric surgery arecovered fee-for-service for these complications 90 days from the date ofthe Agency-approved bariatric surgery. The Agency requires authorizationfor these services. Claims without authorization will be denied.
Agency approved hospitals and clinics are listed in the provider manual.
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WEST VIRGINIAMountain Health Choices
Nutritional Assessment/Counseling246,247 Pharmaceutical Therapy Bariatric Surgery248Adults: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
EPSDT:Obesity services outside of mandated EPSDTservices are not explicitly mentioned.
Excluded (not included in drug formulary or mentionedin provider manual).
The West Virginia Medicaid Program covers bariatric surgeryprocedures subject to the following conditions (truncated descriptions –refer to source for full requirements): Medical Necessity Review and Prior Authorization
o 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.
o The obesity has incapacitated the patient from normal activity,or rendered the individual disabled.
o Must be between the ages of 18 and 65. (Specialconsiderations apply if the individual is not in this age group.If the individual is below the age of 18, submitteddocumentation must substantiate completion of bone growth.)
o The patient must have a documented diagnosis of diabetes thatis being actively treated with oral agents, insulin, or dietmodification.
o Patient must have documented failure at two attempts ofphysician supervised weight loss, attempts each lasting sixmonths or longer.
o Patient must have had a preoperative psychological and/orpsychiatric evaluation within the six months prior to thesurgery.
o The patient must demonstrate ability to comply with dietary,behavioral and lifestyle changes necessary to facilitatesuccessful weight loss and maintenance of weight loss.
o Patient must be tobacco free for a minimum of six monthsprior to the request.
o Contraindications: Three (3) or more prior abdominalsurgeries; history of failed bariatric surgery; current cancertreatment; Crohn’s disease; End Stage Renal Disease (ESRD);prior bowel resection; ulcerative colitis; history of cancerwithin prior 5 years that is not in remission; prior history ofnon-compliance with medical or surgical treatments.
o Documentation of a current evaluation for medical clearanceof this surgery performed by a cardiologist or pulmonologistmust be submitted to ensure the patient can withstand thestress of the surgery from a medical standpoint.
Specified physician credentialing requirements also apply.
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WISCONSINForwardHealth
NutritionalAssessment/Counseling249,250
Pharmaceutical Therapy251 Bariatric Surgery252
Adults:Weight management services (e.g., dietclinics, obesity programs, weight lossprograms) are reimbursable only ifperformed by or under the direct, on-sitesupervision of a physician and only ifperformed in a physician's office. Weightmanagement services exceeding five visitsper calendar year require PA.
Submit claims for weight managementservices with the appropriate E&M(evaluation and management) procedurecode. For weight management services, foodsupplements, and dietary supplies (e.g.,liquid or powdered diet foods orsupplements, over-the-counter diet pills, andvitamins) that are dispensed during an officevisit are not separately reimbursable byWisconsin Medicaid.
CPT Codes: 99401-99404, S9445
EPSDT:Obesity services outside of mandated EPSDTservices are not explicitly mentioned.
Requires prior authorization and meeting specified clinical criteria.
Clinical criteria for approval of a prior authorization request for anti-obesity drugs require one of 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
and two 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 be 12 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 member does not have a medical contraindication to the
selected medication. The member has participated in a weight loss treatment plan (e.g.,
nutritional counseling, an exercise regimen, a calorie-restricted diet)in the past six months and will continue to follow the treatment planwhile taking an anti-obesity drug.
PA requests for anti-obesity drugs will not be renewed if amember's BMI is below 24.
Note: OTC anti-obesity drugs are noncovered drugs. ForwardHealth willreturn prior authorization requests for OTC brand name anti-obesity drugswith generic equivalents and brand name phentermine products asnoncovered services.
Additional criteria such as benchmark weight loss requirements tocontinue therapy apply to certain drugs. Refer to source for full criteria.
All covered bariatric surgery procedures (CPT procedure codes43644, 43645, 43770-43775, 43843, 43846-43848) require priorauthorization. A bariatric procedure that does not meet the priorauthorization approval criteria is considered a noncovered service.
The approval criteria for prior authorization requests for coveredbariatric surgery procedures include all of the following: The member has a BMI greater than 35 with at least one
documented high-risk, life limiting comorbid medical conditionscapable of producing a significant decrease in health status that aredemonstrated to be unresponsive to appropriate treatment. There isevidence that significant weight loss can substantially improve thefollowing comorbid conditions:o Sleep apnea; poorly controlled Diabetes Mellitus while
compliant with appropriate medication regimen; poorlycontrolled hypertension while compliant with appropriatemedication regimen; obesity related cardiomyopathy.
o The member has been evaluated for adequacy of prior effortsto lose weight. If there have been no or inadequate priordietary efforts, the member must undergo 6 months of amedically supervised weight reduction program. This isseparate from and not satisfied by the dietician counselingrequired as part of the evaluation for bariatric surgery.
o The member has been free of illicit drug use and alcoholabuse or dependence for the 6 months prior to surgery.
o The member has been obese for at least 5 years.o The member has had a medical evaluation from the member's
primary care physician, assessing preoperative condition andsurgical risk and finding the member to be an appropriatecandidate.
o The member has received a preoperative evaluation by anexperienced and knowledgeable multidisciplinary bariatrictreatment team composed of health care providers withmedical, nutritional, and psychological experience.
o Must be performed in an ASMBS certified “Center ofExcellence”
Additional criteria apply, refer to source for full list.
EPSDT:During each Well Child Screen, providers need to assessthe child’s growth. All measurements should be plottedon the National Center for Health Statistics (NCHS)Growth Chart. Growth assessments should bedocumented in the medical record and any abnormalityshould be addressed as abnormal if: If a child’s height and/or weight is below the 5th
percentile or above the 95th percentile; or If weight for height is below the 10th percentile or
above the 90th percentile (using the weight for heightgraph).
Nutritional Services - Providers should assess thenutritional status at each Well Child Screen through thefollowing activities: Inquire about dietary practices to identify unusual
eating habits. Unusual eating habits include pica behavior,
extended use of bottle feedings, or diets deficient orexcessive in one or more nutrients;
A complete physical examination including an oralinspection; and
Accurate measurements of height and weight (allmeasurements should be plotted on the NationalCenter for Health Statistics Growth Charts).
NOTE: Children with nutritional problems may be referredto a licensed nutritionist or dietician for further assessment,counseling, or education as needed.
Anorexiant products are specifically excluded. Medicaid will consider coverage of gastric bypass surgery on adults on a case-by-case basis, with the appropriate documentation, if it is medically appropriate forthe individual to have such surgery and if the surgery is to correct an illness thatis aggravated by the obesity.
To receive prior authorization (Section 6.12, Prior Authorization) and to qualifyfor Medicaid reimbursement, the following criteria must be met. The client must meet the weight criteria for clinically severe obesity, which
is a Body Mass Index (BMI) equal to or greater than 40, or 35-40 with co-morbid conditions. Documentation of the client’s BMI and obesity relatedco-morbid medical conditions exacerbated by the obesity are required.
The primary physician must submit a complete client history and physicalexamination notes, including a three-year record of the client’s weight anddocumented efforts to lose weight by conventional means. Conventionalmeans must describe at least two different non-surgical programs of dietaryregimens that include appropriate exercise and a supported behavioralmodification program utilizing licensed mental health therapists.
Documentation of pre-operative psychological evaluation by a psychiatristor licensed clinical psychologist affiliated with a clinic (not associated withthe physician’s group recommending the procedure); within the last 90 daysto determine if the client has the emotional stability to follow through withthe medical regimen that must accompany the surgery.
Physician documentation: Weight control medications currently taken, or taken in the past, and the
duration of time on these medications Proposed treatment plan Client’s goal weight Documentation of lab work up to include: Liver function Lipid level for all Renal panel CBC Thyroid panel Two fasting blood sugars or a two-hour Glucose Tolerance Test
Additional criteria apply (refer to source for full restrictions).
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Appendix: Mandated EPSDT Services257
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 amelioratehealth conditions, 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, corrector reduce 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 medicalnecessity on a 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 madewithout delay 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.
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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 consultwith recognized medical organizations involved in child health care in developing their schedules. Alternatively, states may elect to use a nationally recognized pediatricperiodicity schedule (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.
258
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SOURCES:
Note: All electronic sources were visited between August-September 2012.
1Alabama Medicaid Agency. Physician Fee Schedule (updated July 1, 2012). Available at: http://www.medicaid.alabama.gov/CONTENT/6.0_Providers/6.6_Fee_Schedules.aspx
2 Alabama Medicaid Agency. Provider Manual. Ch. 16 §2.4 (2012). Available at: http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.6_Provider_Manual_2012/6.7.6.3_July_2012/6.7.6.3_provman.pdf3 Alabama Medicaid Agency. Provider Manual. Ch. 100 §100-3 (2012). Available at:http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.6_Provider_Manual_2012/6.7.6.3_July_2012/6.7.6.3_provman.pdf4 Alabama Medicaid Agency. Provider Manual. A §A-12 (2012). Available at: http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.6_Provider_Manual_2012/6.7.6.3_July_2012/6.7.6.3_provman.pdf5 Alabama Medicaid Agency. Provider Manual. Ch 17 §17-3 (2012). Available at: http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.6_Provider_Manual_2012/6.7.6.3_July_2012/6.7.6.3_provman.pdf6 Alabama Medicaid Agency. Provider Manual. Ch 27 §27-2 (2012). Available at: http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.6_Provider_Manual_2012/6.7.6.3_July_2012/6.7.6.3_provman.pdf7 Alabama Medicaid Agency. Provider Manual. Ch 28 §28-9 (2012). Available at: http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.6_Provider_Manual_2012/6.7.6.3_July_2012/6.7.6.3_provman.pdf8 Alabama Medicaid Agency. Provider Manual. Ch 28 §28-2-2 (2012). Available at:http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.6_Provider_Manual_2012/6.7.6.3_July_2012/6.7.6.3_provman.pdf9 Alaska Medical Assistance Program. Physician Fee Schedule. Available at: http://medicaidalaska.com/providers/FeeSchedule.asp10 Alaska Department of Health and Social Services. Alaska Medicaid Recipient Services (2012). Available at: http://www.hss.state.ak.us/dhcs/medicaid_medicare/news_medicaid/MedicaidRecipientHandbook1.pdf pg. 1811 Alaska Department of Health and Social Services. Alaska Medicaid Recipient Services (2012). Available at: http://www.hss.state.ak.us/dhcs/medicaid_medicare/news_medicaid/MedicaidRecipientHandbook1.pdf pg. 1512 Alaska Department of Health and Social Services. Alaska Medicaid Recipient Services (2012). Available at: http://www.hss.state.ak.us/dhcs/medicaid_medicare/news_medicaid/MedicaidRecipientHandbook1.pdf pg. 2113 Alaska Medical Assistance Program. Nutrition Services Provider Billing Manual. Available at: http://medicaidalaska.com/Downloads/Providers/BillingManual_Nutrition.pdf14 Alaska Medical Assistance Program. Provider Billing Manuals Section I: Pharmacy Services Policies and Procedures (revised March 20, 2012). Available at: http://medicaidalaska.com/dnld/PBM_Pharmacy.pdf15 Alaska Medical Assistance Program. Inpatient/Outpatient Hospital Services Provider Billing Manual. Table I-2 (revised March 2006). Available at:http://medicaidalaska.com/Downloads/Providers/BillingManual_IP_OP_Hospital.pdf16 Arizona Health Care Cost Containment System Administration (AHCCCS). AHCCCS Physician Fee Schedule (effective July 1, 2012). Available at:http://www.azahcccs.gov/commercial/ProviderBilling/rates/Physicianrates/2012July/2012FFScodes.aspx17 AHCCCS. AHCCCS Medical Policy for AHCCCS Covered Services: §430-7 – 430-10 (2012).18 AHCCCS. AHCCS Contractor Operations Manual. Available at: http://www.azahcccs.gov/shared/Downloads/ACOM/ACOM.pdf pg. 2019 Arkansas Medicaid. Arkansas Medicaid Physician Fee Schedule. Available at: https://www.medicaid.state.ar.us/InternetSolution/provider/docs/pcp.aspx20
Arkansas Medicaid. Provider Manual. §II-203.120 (2012).21 Arkansas Medicaid. Provider Manual. §II-251.270 (2012).22 California Department of Healthcare Services. Medi-Cal Rates Codes 94799 – 99499 (as of August 15, 2012). Available at: http://files.medi-cal.ca.gov/pubsdoco/rates/rates_information.asp?num=22&first=94799&last=9949923 California Department of Healthcare Services. Medi-Cal Rates Codes L6905 – X4930 (as of August 15, 2012). Available at: http://files.medi-cal.ca.gov/pubsdoco/rates/rates_information.asp?num=25&first=L6905&last=X493024
California Department of Healthcare Services. TAR and Non-Benefit List: Codes 90000 – 99999. Codes 97802-97804. Available at: https://www.google.com/url?q=http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/tarandnoncd9_m00i00o03.doc&sa=U&ei=oo8uUOqxBuaN0QGcqIG4BA&ved=0CBIQFjAGOEY&client=internal-uds-cse&usg=AFQjCNEsTJ1wAgc_dfjsB2lxD_ioDZ2Ibg25 California Department of Healthcare Services. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). Available at: http://www.dhcs.ca.gov/services/Pages/EPSDT.aspx26 California Department of Healthcare Services. Medi-Cal Provider Manual: General Medicine: Surgery: Digestive System. Available at: http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/surgdigest_m01o03.doc27 Colorado Department of Health Care Policy and Financing. Fee Schedule Data File (effective July 1, 2011). Available at: http://www.colorado.gov/cs/Satellite/HCPF/HCPF/125156707055728
Colorado Medical Assistance Program. Medical/Surgical Manual (2012). Available at:http://www.colorado.gov/cs/Satellite?c=Document_C&childpagename=HCPF%2FDocument_C%2FHCPFAddLink&cid=1251570865952&pagename=HCPFWrapper pg. 1629 Colorado Medical Assistance Program. EPDST Manual (2012). Available at:http://www.colorado.gov/cs/Satellite?c=Document_C&childpagename=HCPF%2FDocument_C%2FHCPFAddLink&cid=1250162663139&pagename=HCPFWrapper pg. 5-630 Colorado Medical Assistance Program. Provider Bulletin. Ref Number: B1000288 (September 2010). Available at:http://www.colorado.gov/cs/Satellite?c=Document_C&childpagename=HCPF%2FDocument_C%2FHCPFAddLink&cid=1251580116559&pagename=HCPFWrapper31
Colorado Medical Assistance Program. Colorado Medicaid Benefits Collaborative Policy Statement: Bariatric Surgery (2010). Available at:http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251731791134&ssbinary=true32 Connecticut Department of Social Services. Physician Office and Outpatient Services Provider Fee Schedule. Available at:https://www.ctdssmap.com/CTPortal/Provider/Provider%20Fee%20Schedule%20Download/tabId/54/Default.aspx
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33 Connecticut Medical Assistance Program. Pharmacy Services Regulation/Policy. Chapter 7. Available at:https://www.ctdssmap.com/CTPortal/Information/Get%20Download%20File/tabid/44/Default.aspx?Filename=ch7_iC_pharm_V1.0.pdf&URI=Manuals/ch7_iC_pharm_V1.0.pdf&PopUp=Y34 Connecticut Department of Social Services. Provider Drug Search. Available at: https://www.ctdssmap.com/CTPortal/Provider/Drug%20Search/tabId/53/Default.aspx35 Connecticut Department of Social Services. Provider Manual. Chapter 7. Available at:https://www.ctdssmap.com/CTPortal/Information/Get%20Download%20File/tabid/44/Default.aspx?Filename=ch7_iC_physician_V2.0.pdf&URI=Manuals/ch7_iC_physician_V2.0.pdf&PopUp=Y36 Connecticut Department of Social Services. Physician Surgical Provider Fee Schedule. Available at: https://www.ctdssmap.com/CTPortal/Provider/Provider%20Fee%20Schedule%20Download/tabId/54/Default.aspx37 Delaware Medical Assistance Program. DMMA 2012 Physician Fee Schedule. Available at: http://www.dmap.state.de.us/downloads/hcpcs.html38
Delaware Medical Assistance Program. Delaware Provider Policy Manual: Federally Qualified Health Centers Provider Specific Policy. §2.5.2.12. Available at:http://www.dmap.state.de.us/downloads/manuals/FQHC.Provider.Specific.pdf39 Delaware Medical Assistance Program. Provider Policy Manual: General Policy. §1.15.1. Available at: http://www.dmap.state.de.us/downloads/manuals/General.Policy.Manual.pdf40 Delaware Medical Assistance Program. Provider Policy Manual: Pharmacy. §3.5.6. Available at: http://www.dmap.state.de.us/downloads/manuals/Pharmacy.Provider.Specific.pdf41 Delaware Medical Assistance Program. Provider Policy Manual: Inpatient Hospital. §2.9. Available at: http://www.dmap.state.de.us/downloads/manuals/Inpatient.Hospital.Provider.Specific.pdf42 DC Department of Health Care Finance. Fee Schedule. Available at: https://www.dc-medicaid.com/dcwebportal/nonsecure/feeScheduleDownload43
DC Department of Health Care Finance. MMIS Provider Billing Manual: EPSDT Billing Manual. §12.4 (June 2012). Available at: https://www.dc-medicaid.com/dcwebportal/documentInformation/getDocument/569344 DC Department of Health Care Finance. District of Columbia Pharmacy Benefits Management: Prescription Drug Claim System Provider Manual (April 2012). Available at:http://www.dcpbm.com/documents/DC%20MAA%20Provider%20Manual%20v100412.pdf45 DC Department of Health Care Finance. DC MMIS Provider Billing Manual: Physicians. §12.5.2 (June 2012). Available at: https://www.dc-medicaid.com/dcwebportal/documentInformation/getDocument/572546 Florida Agency for Health Care Administration. Physician Evaluation and Management Provider Fee Schedule. Available at:http://portal.flmmis.com/FLPublic/Provider_ProviderSupport/Provider_ProviderSupport_FeeSchedules/tabId/44/Default.aspx47 Florida Agency for Health Care Administration. Practitioner Services Coverage and Limitations Handbook.48 Florida Agency for Health Care Administration. Summary of Services, Fiscal Year 2011-2012. Available at: http://www.fdhc.state.fl.us/Medicaid/pdffiles/FY_2011-12_Florida_Medicaid_Summary_of_Services.zip pg.4849 Florida Agency for Health Care Administration. Summary of Services, Fiscal Year 2011-2012. Available at: http://www.fdhc.state.fl.us/Medicaid/pdffiles/FY_2011-12_Florida_Medicaid_Summary_of_Services.zip pg.7650 Florida Agency for Health Care Administration. Practitioner Services Coverage and Limitations Handbook (2012).51 Georgia Department of Community Health. PART II Policies and Procedures for Diagnostic, Screening, and Preventive Services. §601.2. Available at:https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Diagnostic%20Screening%20and%20Preventive%20Services%20July%202012%20V2%2029-06-2012%20182446.pdf52 Georgia Department of Public Health. Public Health Billing Resource Manual. §5.3, §6.5, §7.6 (June 2012). Available at: http://health.state.ga.us/pdfs/publications/manuals/DPH%20Billing%20Resource%20Manual.pdf53 Georgia Department of Community Health. PART II Policies and Procedures for Pharmacy Services. §901.1. Available at:https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/V4%20July%202012%20Pharmacy%2029-06-2012%20203822.pdf54 Georgia Department of Community Health. PART II Policies and Procedures for Physician Services. Appendix E. Available at:https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Physician%20Services%2026-04-2012%20155057.pdf55 WellCare Bariatric Surgery Coverage. Policy Document. Policy Number HS-006 (updated November 2011). Available at: https://www.wellcare.com/WCAssets/corporate/assets/HS006_Bariatric_Surgery.pdf56 Hawaii Department of Human Services. Medicaid Fee Schedule. Available at: http://www.med-quest.us/providers/Providers.html57 Hawaii Department of Human Services. Medicaid Provider Manual: Medical Surgical Services. §6.10.2. Available at: http://www.med-quest.us/PDFs/Provider%20Manual/PMChp0611.pdf58 Hawaii Department of Human Services. Medicaid Provider Manual: EPSDT. Available at: http://www.med-quest.us/PDFs/Provider%20Manual/PMChp0511.pdf59 Hawaii Department of Human Services. Medicaid Provider Manual: Pharmacy. §19.1.5. Available at: http://www.med-quest.us/PDFs/Provider%20Manual/PMChp1911.pdf60 Hawaii Department of Human Services. Medicaid Provider Manual: Medical Surgical Services. §6.16.4. Available at: http://www.med-quest.us/PDFs/Provider%20Manual/PMChp0611.pdf61
Hawaii Department of Human Services. Medicaid Provider Manual: Medical Surgical Services. Available at: http://www.med-quest.us/PDFs/Provider%20Manual/PMChp0611.pdf pg.4262 Idaho Department of Health and Welfare. Medicaid Fee Schedule. Available at: http://www.healthandwelfare.idaho.gov/Providers/MedicaidProviders/MedicaidFeeSchedule/tabid/268/Default.aspx63 Idaho Department of Health and Welfare. Idaho MMIS Provider Handbook: General Provider and Participant Information (November 2011). Available at:https://www.idmedicaid.com/General%20Information/General%20Provider%20and%20Participant%20Information.pdf pg.2364 Idaho Department of Health and Welfare. Idaho MMIS Provider Handbook: Dietary and Nutrition Service Providers (August 2010). Available at:https://www.idmedicaid.com/Provider%20Guidelines/Dietary%20and%20Nutritional%20Services.pdf65
Idaho Admin. Code §432-432 (2012). Available at: http://adminrules.idaho.gov/rules/2012/16/0309.pdf66 Idaho Department of Health and Welfare. Idaho MMIS Provider Handbook: Hospital (January 2012). Available at: https://www.idmedicaid.com/Provider%20Guidelines/Hospital.pdf pg. 2267 Idaho Admin. Code §432-432 (2012). Available at: http://adminrules.idaho.gov/rules/2012/16/0309.pdf68 Illinois Healthcare and Family Services. Practitioner Fee Schedule (revised 8/21/12). Available at: http://www.hfs.illinois.gov/assets/082112fee.pdf69 Illinois Department of Healthcare and Family Services. Handbook for Providers of Healthy Kids Services. Ch. HK-200 §HK-205 (March 2008). Available at: http://www.hfs.illinois.gov/assets/hk200.pdf70 Illinois Department of Healthcare and Family Services. Handbook for Providers of Healthy Kids Services. Ch. HK-200 §HK-203.1.4 (March 2008). Available at: http://www.hfs.illinois.gov/assets/hk200.pdf71
Illinois Department of Healthcare and Family Services. Handbook for Providers of Pharmacy Services. Ch. P-200 §P-206.3 (November 2010). Available at: http://www.hfs.illinois.gov/assets/p200.pdf72 Illinois Department of Healthcare and Family Services. Handbook for Providers Rendering Medical Services. Ch. A-200: §A-222.5 (Aug 2010). Available at: http://www.hfs.illinois.gov/assets/a200.pdf73 Indiana Family and Social Services Administration. Indiana ICHP Fee Schedule (updated August, 28 2012). Available at: http://www.indianamedicaid.com/ihcp/Publications/MaxFee/fee_home.asp
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74 405 IND. ADMIN. CODE § 5-15-3 (2012).75
405 IND. ADMIN. CODE § 5-29-1 (2012).76 405 IND. ADMIN. CODE § 5-31-5 (2012).77 405 IND. ADMIN. CODE § 5-24-3 (2012).78 405 IND. ADMIN. CODE § 5-3-13 (2012).79 Iowa Department of Human Services. Open Fee Provider Fee Schedules (revised January 2012). Available at: http://www.ime.state.ia.us/Reports_Publications/FeeScheduleAgreement.html80 Iowa Department of Human Services. Medicaid Provider Manual: Institutional Care: Acute Care (2011). Available at: http://www.dhs.iowa.gov/policyanalysis/PolicyManualPages/Manual_Documents/Provman/ahosp.pdfpg. 881 Iowa Department of Human Services. Medicaid Provider Manual: Institutional Care: Acute Care (2011). Available at: http://www.dhs.iowa.gov/policyanalysis/PolicyManualPages/Manual_Documents/Provman/ahosp.pdfpg. 5282 Iowa Department of Human Services. Medicaid Provider Manual: Prescribed Drugs. Available at: www.dhs.iowa.gov/policyanalysis/PolicyManualPages/Manual_Documents/Provman/drugs.pdf pg. 1783 Iowa Department of Human Services. Medicaid Provider Manual: General Program Policies (2011). Available at: http://www.dhs.iowa.gov/policyanalysis/PolicyManualPages/Manual_Documents/Provman/all-i.pdf pg.28-3584
Iowa Department of Human Services. Medicaid Provider Manual: Institutional Care: Acute Care (2011). Available at: http://www.dhs.iowa.gov/policyanalysis/PolicyManualPages/Manual_Documents/Provman/ahosp.pdfpg. 1485 Kansas Medical Assistance Program. KMAP Fee Schedules: QMB and MediKan. Available at: https://www.kmap-state-ks.us/Provider/Pricing/ScheduleList.asp86 Kansas Medical Assistance Program. Provider Manual: Dietitian (May 2012). Available at: https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/DIETITIAN%2005182012_12055.pdf87 Kansas Medical Assistance Program. Provider Manual: General Benefits (July 2011). Available at: https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/Gen%20benefits_02242012_12025.pdf88 Kansas Medical Assistance Program. Provider Manual: General Benefits (July 2011). Available at: https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/Gen%20benefits_02242012_12025.pdf89 Kansas Medical Assistance Program. Provider Manual: Pharmacy (April 2012). Available at: https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/PHARMACY_08232012_12088.pdf90 Kentucky Department for Medicaid Services, Cabinet for Family and Health Services. Physician Fee Schedule. Available at: http://www.chfs.ky.gov/dms/fee.htm91 Kentucky Department for Medicaid Services, Cabinet for Family and Health Services. Eligibility for Early Periodic Screening, Diagnosis and Treatment Service. Available at: http://chfs.ky.gov/dms/epsdt.htm92 Kentucky Department for Medicaid Services, Cabinet for Family and Health Services. Kentucky Medicaid Provider Manual (2012) Available at:https://kentucky.wellcare.com/WCAssets/kentucky/assets/WellCare_ProviderManual_tagged_approved083011.pdf pg.7293 WellCare Bariatric Surgery Coverage. Policy Document: Policy Number HS-006 (updated November 2011). Available at: https://www.wellcare.com/WCAssets/corporate/assets/HS006_Bariatric_Surgery.pdf94 Louisiana Medicaid. Professional Services Fee Schedule for Dates of Service on or After July 2, 2012. Available at: http://www.lamedicaid.com/provweb1/fee_schedules/ProfServ_FS.htm95 Louisiana Bureau of Health Services Financing. Personal Care Service Provider Manual. Chapter 30 §30.14 (issued November 2009). Available at:http://www.lamedicaid.com/provweb1/Providermanuals/manuals/PCS/pcs.pdf96 Louisiana Department of Health and Human Services. Medicaid Program Provider Manual: Pharmacy Benefits Management Services. Chapter 37.7.5 Available at:http://www.lamedicaid.com/provweb1/manuals/pharm_benefits_manual.pdf97 Louisiana Department of Health and Human Services: Medicaid Services Manual: Professional Services Provider. Chapter 5:5.1. Available at: http://www.lamedicaid.com/provweb1/Providermanuals/manuals/PS/PS.pdf98 Maine Department of Health and Human Services. MaineCare Provider Fee Schedules August 2012. Available at: https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx99 Maine Department of Health and Human Services. MaineCare Benefits Manual. Chapter 2-Section 94- Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT). Available at:http://www.maine.gov/sos/cec/rules/10/144/ch101/c2s094.doc100 Maine Department of Health and Human Services. MaineCare Benefits Manual. Chapter 2-Section 80- Pharmacy Services. Available at: http://www.maine.gov/sos/cec/rules/10/ch101.htm101 Maine Department of Health and Human Services. MaineCare Benefits Manual. Chapter 2-Section 90- Restricted Services. Available at: http://www.maine.gov/sos/cec/rules/10/ch101.htm102
Maryland Physicians Care MCO. Provider Manual: January 2012. Available at: http://www.marylandphysicianscare.com/PDF/MPC_HEALTHCHOICE_PROVIDER_MANUAL_FINAL_01_12_2012.pdf pg. 84103 Maryland Physicians Care MCO. Provider Manual: January 2012. Available at: http://www.marylandphysicianscare.com/PDF/MPC_HEALTHCHOICE_PROVIDER_MANUAL_FINAL_01_12_2012.pdf104 http://mmcp.dhmh.maryland.gov/docs/Physicians_FeeSchedule_2011_2.pdf105 Massachusetts Department of Health and Human Services. MassHealth Service Codes and Descriptions: Physicians. Available at: http://www.mass.gov/eohhs/provider/insurance/masshealth/claims/masshealth-service-codes-and-descriptions.html106 Massachusetts Department of Health and Human Services. Provider Manual: Administrative and Billing Regulations. Available at: http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-allprovider.pdf107
Massachusetts Department of Health and Human Services. Provider Manual: Physician Regulations. Available at: http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-physician.pdf108 Massachusetts Department of Health and Human Services. Provider Manual: Physician Regulations. Available at: http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-physician.pdf109 Massachusetts Department of Health and Human Services. Guidelines for Medical Necessity Determination for Bariatric Surgery. Available at: http://www.mass.gov/eohhs/docs/masshealth/guidelines/mg-bariatricsurgery.pdf110 Michigan Department of Community Health. Practitioner and Medical Clinic July 2012 Fee Schedule. Available at: http://www.michigan.gov/mdch/0,1607,7-132-2945_42542_42543_42546_42551-151022--,00.html111 Michigan Department of Community Health. Medicaid Provider Manual: Weight Reduction. Section 3.34. Available at: http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf pg 31112
Michigan Department of Community Health. Medicaid Provider Manual. Section 8.5b. Available at: http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf pg 15113 Michigan Department of Community Health. Medicaid Provider Manual: Weight Reduction. Section 3.34. Available at: http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf pg 31
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114 Minnesota Department of Human Services. MHCP Fee Schedule. Available at:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_010122115 Minnesota Department of Human Services. MHCP Provider Manual, Medical Nutritional Therapy (revised August 2012). Available at:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&dDocName=id_008926&RevisionSelectionMethod=LatestReleased#P53_1496116 Minnesota Department of Human Services. MHCP Provider Manual, Pharmacy Services, Drug Categories with Limited Coverage (revised August 2012). Available at:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_138889#117 Minnesota Department of Human Services. MHCP Provider Manual, Physician and Professional Services, Authorization Standards for Adult Bariatric Surgery (revised August 2012). Available at:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&dDocName=id_008926&RevisionSelectionMethod=LatestReleased#P53_1496118 Mississippi Division of Medicaid. OPPS Medicaid Fee Schedule. Available at: http://www.medicaid.ms.gov/FeeScheduleLists.aspx119 Mississippi State Department of Health. The Cool Kids Program. Available at: http://www.msdh.state.ms.us/msdhsite/_static/41,0,164.html120 Mississippi Division of Medicaid. Provider Policy Manual. Section 31.07-31.08. Available at: http://www.medicaid.ms.gov/Manuals/Section%2031%20-%20Pharmacy/Section%2031.07%20-%20Non-Convered%20Pharmacy%20Services.pdf pg.1121 Mississippi Division of Medicaid. Provider Policy Manual. Section 2.03. Available at: http://www.medicaid.ms.gov/Manuals/Section%202%20-%20Benefits/Section%202.03%20-%20Exclusions.pdf pg.2122
Missouri Department of Social Services. “Medical Services Fee Schedule.” MHD Price List Search. Available at: https://dssapp3.dss.mo.gov/FeeSchedules/fsmain.aspx123 Missouri Department of Social Services. Medical Services: MO HealthNet, Family Support Division. Available at: http://dss.mo.gov/fsd/msmed.htm124 Missouri Department of Social Services. MO HealthNet Manuals: Benefits and Limitations. Section 13. Available at: http://207.15.48.5/collections/collection_phy/Physician_Section13.pdf125 Montana Department of Public Health and Human Services. “RBRVS Fee Schedule for State Fiscal Year 2013.” Montana Medicaid Provider Information. Available at: http://medicaidprovider.hhs.mt.gov/126 Montana Department of Health and Human Services. Medicaid and Other Medical Assistant Programs. Section 2.2-2.10 (March 2012). Available at: http://medicaidprovider.hhs.mt.gov/pdf/manuals/nutrition.pdf127 Montana Department of Health and Human Services. Medicaid Prescription Drug Program. Section 2.2 (August 2011). Available at: http://medicaidprovider.hhs.mt.gov/pdf/pharmacym09012011.pdf128 Montana Department of Health and Human Services. Medicaid and Other Medical Assistant Programs. Section 2.10 (March 2012). Available at: http://medicaidprovider.hhs.mt.gov/pdf/manuals/nutrition.pdf129 Nebraska Department of Health and Human Services. Physician Services Fee Schedule 2012. Available at: http://dhhs.ne.gov/medicaid/Pages/med_practitioner_fee_schedule.aspx130 Nebraska Department of Health and Human Services. Services Covered by Medicaid. Available at: http://dhhs.ne.gov/medicaid/Pages/med_medserv.aspx#Check131 Nebraska Medicaid Program. Provider Information Pharmacy Provider Handbook. 16-003. Available at: http://www.sos.state.ne.us/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-471/Chapter-16.pdf132 Nevada Department of Health and Human Services: Division of Health Care Financing and Policy. Physician Services. Attachment A. Available at: http://dhcfp.nv.gov/MSM/CH0600/MSM%20Ch%20600%20FINAL%205-8-12.pdf pg.9-22133 Nevada Department of Health and Human Services: Division of Health Care Financing and Policy. Physician Services. Attachment A. Available at: http://dhcfp.nv.gov/MSM/CH0600/MSM%20Ch%20600%20FINAL%205-8-12.pdf pg.9-22134 Nevada Department of Health and Human Services. Provider Type 20 Physician Professional Rates. Available at: http://dhcfp.state.nv.us/RatesUnit.htm?Accept135 Nevada Department of Health and Human Services: Division of Health Care Financing and Policy. Prescribed Drugs. Section 1203 (updated April 18, 2012). Available at:http://dhcfp.nv.gov/MSM/CH1200/MSM%20Ch%201200%20FINAL%204-17-12.pdf pg.3136 Nevada Department of Health and Human Services: Division of Health Care Financing and Policy. Physician Services. Attachment A. Available at: http://dhcfp.nv.gov/MSM/CH0600/MSM%20Ch%20600%20FINAL%205-8-12.pdf pg.9-22137 New Hampshire Department of Health and Human Services. NH Covered Procedures 2012. Available at: http://www.nhmedicaid.com/Downloads/schedules.codes.html138 New Hampshire Department of Health and Human Services. Physician Provider Manual, Specific Billing Guidelines. Available at: http://www.nhmedicaid.com/Downloads/manuals.html139 New Hampshire Department of Health and Human Services. Clinical Prior Authorization Program. Available at: http://www.dhhs.nh.gov/ombp/pharmacy/authorization.htm140 New Hampshire Medicaid: Schaller Anderson Medical Administrators, Inc. Form 274GB: Gastric Bypass Surgery Prior Authorization Request (April 2011). Available at:http://www.mynewhampshirecare.com/documents/Gastric_Bypass_Surgery_Prior_Authorization_request.pdf141 NJMMIS. Procedure Master Listing – Medicaid Fee for Services. Available at: https://www.njmmis.com/hospitalinfo.aspx142 N.J.A.C. 10:51-1.13: Pharmaceutical Services. Available at: http://web.lexisnexis.com/research/xlink?app=00075&view=full&interface=1&docinfo=off&searchtype=get&search=N.J.A.C.+10%3A51-1.13143 N.J.A.C. 10:49-5.7: Services Covered by Medicaid and the NJ FAMILYCARE Programs. Available at:http://web.lexisnexis.com/research/xlink?app=00075&view=full&interface=1&docinfo=off&searchtype=get&search=N.J.A.C.+10%3A49-5.7144 N.J.A.C. 10:52-14.4: Methodology for Establishing DRG Payment Rates for Inpatient Services at General Acute Care Hospitals Based on DRG Weights and a Statewide Base Rate. Available at:http://web.lexisnexis.com/research/xlink?app=00075&view=full&interface=1&docinfo=off&searchtype=get&search=N.J.A.C.+10%3A52-14.4145 New Mexico Human Services Department. Medicaid Fee for Service CPT Code Fee Schedule. Available at: http://www.hsd.state.nm.us/mad/PCptDisclaimer.html146 N.M. Admin. Code 8.324.9.14.147 N.M. Admin. Code 8.324.4.14(A)(8).148 N.M. Admin. Code 8.301.3.31.149 New York Department of Health, Office of Medicaid Management. Procedure Codes Medicine and Drugs. Available at: https://www.emedny.org/ProviderManuals/Physician/index.aspx andhttps://www.emedny.org/ProviderManuals/Physician/PDFS/Physician_Procedure_Codes_Sect2.pdf150 New York Department of Health, Office of Medicaid Management. EPSDT/CTHP Provider Manual 38 (2005 version). Available at: http://www.emedny.org/ProviderManuals/EPSDTCTHP/PDFS/EPSDT-CTHP.pdf
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151 Ibid.152
Ibid.153 N.Y. Comp. Codes R & Regs. 18, §505.3 (2012).154 New York Department of Health. New Protocol for Gastric Bypass Surgery (2005). Available at: http://www.health.state.ny.us/health_care/medicaid/program/update/2005/jan2005.htm#prot155 New York Department of Health. New York State Medicaid Update (January 2011). Available at: http://www.health.ny.gov/health_care/medicaid/program/update/2011/2011-01.htm#bar156 North Carolina Division of Medical Assistance. Physician Services Fee Schedule (CPT/HCPCS). Available at: http://www.ncdhhs.gov/dma/fee/index.htm157 North Carolina Division of Medical Assistance. Child Service Coordination (version September 1, 2010). Available at: http://www.dhhs.state.nc.us/dma/mp/1m1.pdf158
North Carolina Department of Health and Human Services. North Carolina State Plan under Title XIX of the Social Security Act: Medical Assistance Program. Attachment 3.1-A.1 at 7g.7. Available at:http://www.ncdhhs.gov/dma/plan/sp.pdf159 Ibid. Attachment 3.1-B.1 at 4.160 North Dakota Department of Human Services. “2012 ND Medicaid ASC Payment Groups, Rates, and Codes.” Medicaid Provider Information. Available at:http://www.nd.gov/dhs/services/medicalserv/medicaid/provider-fee-schedules.html161 North Dakota Department of Human Services. General Information for Providers: Medicaid and Other Assistance Programs (April 2012 version). Available at:http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/gen-info-providers.pdf162 Ibid, pg.111.163 Ibid, pg.110.164 North Dakota Department of Human Services. Medicaid Management Information System: Provider Manual for Pharmacies 11 (April 2010 version). Available at:http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/pharmacy-manual.pdf.165 North Dakota Department of Human Services, General Information for Providers: Medicaid and Other Assistance Programs 151-4 (April 2012 version).166 North Dakota Health Care Review, Inc. Criteria for Bariatric Surgery. Available at: http://www.ndhcri.org/Healthcare_Professionals/medicaidcasereview/preauthorizationareas/Criteria_for_Bariatric_Surgery.pdf.167 Ohio Department of Jobs and Family Services. Medicaid Fee Schedule. Ohio Health Plans Fee Schedules and Rates. Available at: http://jfs.ohio.gov/ohp/bhpp/feeschdrates.stm168 Ohio Admin. Code Ann. 5101:3-4-34 (2012).169 Ohio Admin. Code Ann. 5101:3-14-03 (2012).170 Ibid.171 Ohio Admin. Code Ann. 5101:3-9-03 (2012).172 Ohio Admin. Code Ann. 5101:3-2-03(2)(d) (2012); Ohio Admin. Code Ann. 5101:3-4-28(F).173 Oklahoma Health Care Authority. Sooner Care Fee Schedules Title XIX (revised July 1, 2012). Available at: http://www.okhca.org/providers.aspx?id=102174 Okla. Admin. Code 317:30-5-1076(5).175 Okla. Admin. Code 317:30-3-57(13); Okla. Admin. Code 317:30-3-65(2).176 Okla. Admin. Code 317:30-3-65.4(1)(A); Okla. Admin. Code 317:30-5-1076(2).177 Okla. Admin. Code 317:30-5-72.1(1)(D).178 Okla. Admin. Code 317-30-5-137.179 Okla. Admin. Code 317:30-5-137.1.180 Okla. Admin. Code 317:30-5-137.2(a).181 Okla. Admin. Code 317:30-5-137.3(b).182 Oregon Health Plan. OHP Fee Schedule for Fee-For-Service Providers. Available at: http://cms.oregon.gov/oha/healthplan/pages/data_pubs/feeschedule/main.aspx#fee_schedule andhttp://cms.oregon.gov/oha/healthplan/data_pubs/feeschedule/2012/2012-08-dmap.pdf183 Or. Admin. R. 410-120-1200(2)(aa).184 Oregon Health Services Commission. Prioritized List of Health Services (April 2012 version). Available at: http://cms.oregon.gov/oha/OHPR/herc/docs/l/apr12list.pdf.185 Or. Admin. R. 410-130-0240.186 Or. Admin. R. 410-121-0040; Table 121-0040-1. Drugs Requiring Prior Authorization for Covered Diagnosis 9. Available at: http://arcweb.sos.state.or.us/pages/rules/oars_400/oar_410/_tables_410/410-121-0040%201215.pdf187
Oregon Division of Medical Assistance Programs. Oregon Health Plan, OHP Preferred List (updated Aug 20, 2012). Available at: http://www.orpdl.org./188 Or. Admin R. 410-130-0200.189 Oregon Health Services Commission. Prioritized List of Health Services (April 2012 version).190 Pennsylvania Department of Public Welfare. Outpatient Fee Schedule. Available at: http://www.dpw.state.pa.us/publications/forproviders/schedules/mafeeschedules/outpatientfeeschedule/index.htm191 55 PA. Code § 1241; Pennsylvania Department of Public Welfare. Pennsylvania Children’s Checkup Program (EPSDT): Periodicity Schedule and Coding Matrix (2005). Available at:http://www.dpw.state.pa.us/PubsFormsReports/NewslettersBulletins/003673169.aspx?AttachmentId=1039; 55 PA. CODE Part III, Ch 1241, Appendix A192
Pennsylvania Department of Public Welfare. Medical Assistance Bulletin: Childhood Nutrition and Weight Management Services for Recipients Under 21 Years of Age (2007). Available at:http://www.dpw.state.pa.us/resources/documents/pdf/maacmtgatt/10- 07mabulletinonchildhoodnutrition.pdf.193 55 PA. Code §1121.54(1).
Rhode Island Department of Human Services. Fee Schedule: 90000 Series Codes. Available at: http://www.dhs.ri.gov/ForProvidersVendors/MedicalAssistanceProviders/FeeSchedules/tabid/170/Default.aspx196 Rhode Island Department of Human Services. Fee Schedule: S Codes. Available at: http://www.dhs.ri.gov/ForProvidersVendors/MedicalAssistanceProviders/FeeSchedules/tabid/170/Default.aspx197 Rhode Island Department of Human Services. Prior Approval for Criteria for Surgical Procedures: Gastric Bypass Surgery. Available at:http://dhs.embolden.com/ForProvidersVendors/MedicalAssistanceProviders/ReferenceGuides/Physician/PriorApprovalCriteriaforSurgicalProcedures/tabid/671/Default.aspx.198 Rhode Island Department of Human Services. Rite Care Program – Overview of the Program (February 2012). Available at: http://sos.ri.gov/documents/archives/regdocs/released/pdf/EOHHS/6784.pdf.199 Rhode Island Department of Human Services. Rhode Island EPSDT Guidelines. Available at: http://www.dhs.ri.gov/Portals/0/Uploads/Documents/Public/Families%20with%20Children/epsdt_1pager.pdf.200
Rhode Island Department of Human Services. Pharmacy Coverage Policy. Available at:http://www.dhs.ri.gov/ForProvidersVendors/ServicesforProviders/ProviderManuals/Pharmacy/PharmacyCoveragePolicy/tabid/660/Default.aspx.201 Ibid.202 South Carolina Health and Human Services. Physicians Fee Schedule: Family Practice, General Practice, Osteopath, Internal Medicine, Pediatrics, Geriatrics. Available at: http://www.scdhhs.gov/resource/fee-schedules203 South Carolina Health and Human Services. Physicians Fee Schedule: OB/GYN, Maternal Fetal Medicine. Available at: http://www.scdhhs.gov/resource/fee-schedules204 South Carolina Health and Human Services. Physicians Fee Schedule: All Other Physicians Excluding Obstetrics, OB/GYN, Maternal Fetal Medicine. Available at: http://www.scdhhs.gov/resource/fee-schedules205
South Carolina Health and Human Services. Medicaid Provider Manual - Physicians 26-7 (August 2012). Available at: http://www.scdhhs.gov/internet/pdf/manuals/Physicians/Manual.pdf206 Ibid, 71.207 Ibid, 51-60.208 South Carolina Health and Human Services. Medicaid Provider Manual – Pharmacy Services 16 (August 2012). Available at: http://www.scdhhs.gov/internet/pdf/manuals/pharm/Manual.pdf209 South Carolina Health and Human Services. Medicaid Provider Manual – Hospital Services 54-5 (August 2012). Available at: http://www.scdhhs.gov/internet/pdf/manuals/Hospital/Manual.pdf210 South Dakota Department of Social Services. Nonlaboratory Procedures – Primary Care Physicians FY 2013. Provider Fee Schedule. Available at: http://dss.sd.gov/sdmedx/includes/providers/feeschedules/dss/index.aspxand http://dss.sd.gov/sdmedx/docs/providers/feeschedules/NonlaboratoryProcedureCodes_PrimaryCarePhysicians9.07.12_FY13.pdf211 South Dakota Department of Social Services. Medical Assistance Program: Nutritional Therapy Manual (September 2011). Available at: http://dss.sd.gov/sdmedx/docs/providers/NutritionalTherapyManual.pdf212 South Dakota Department of Social Services. Pharmacy Manual. Available at:http://dss.sd.gov/sdmedx/docs/providers/PharmacyManual7.12.12.pdf.213 South Dakota Department of Social Services. Provider Information –Prior Authorization Request Services and Forms – Obesity and Gastric Procedures. Available at:http://dss.sd.gov/medicalservices/providerinfo/priorauth/obesity.asp214 South Dakota Department of Social Services. Medical Assistance Program: Nutritional Therapy Manual (September 2011). Available at: http://dss.sd.gov/sdmedx/docs/providers/NutritionalTherapyManual.pdf215 Tennessee Department of Finance and Administration, Bureau of TennCare. TennCare Medicaid. Chapter 1200-13-13. Available at: http://www.tn.gov/tenncare/forms/tsop36-3.pdf216 Tennessee Department of Finance and Administration, Bureau of TennCare. Memorandum from the Deputy Commissioner of the DFA re: EPSDT Screening Requirements. Available at:http://www.tn.gov/tenncare/forms/tsop36-3.pdf217 Tennessee Department of Finance and Administration, Bureau of TennCare. TennCare Medicaid. Chapter 1200-13-13. Available at: http://www.tn.gov/tenncare/forms/tsop36-3.pdf218 Tennessee Department of Finance and Administration. Bureau of TennCare. TennCare Medicaid. Chapter 1200-13-13. Available at: http://www.tn.gov/sos/rules/1200/1200-13/1200-13-13.20120916.pdf pg.36219 Texas Medicaid and Healthcare Partnership. Texas Medicaid Provider Procedures Manual, Volume 1, General Information: Section 4: Client Eligibility: 4.8 Texas Medicaid Wellness Program (August 2012). Available at:http://www.tmhp.com/HTMLmanuals/TMPPM/2012/Vol1_04_Client_Eligibility.06.46.html220 Texas Medicaid and Healthcare Partnership. Texas Medicaid Bulletin: No.237 (September/October 2011). Available at: http://www.tmhp.com/Texas_Medicaid_Bulletin/237_M.pdf221 Texas Medicaid and Healthcare Partnership. Texas Medicaid Provider Procedures Manual, Volume 1, Children’s Services Handbook: 2: Medicaid Children’s Services Comprehensive Care Program: 2.6 Medical NutritionCounseling Services: 2.6.2 Services, Benefits, and Limitations (August 2012). Available at: http://www.tmhp.com/HTMLmanuals/TMPPM/2012/Vol2_Children%27s_Services_Handbook.17.086.html222 Texas Medicaid and Healthcare Partnership. Physician Static Fee Schedule. Available at: http://public.tmhp.com/FeeSchedules/StaticFeeSchedule/FeeSchedules.aspx223
1 TEX ADMIN CODE 354.1923.224 Texas Department of Health and Human Services. Texas Medicaid Program: Provider Manuals, Volume 2, Procedures Manual (August 2012). Available at:http://www.tmhp.com/TMPPM/TMPPM_Living_Manual_Current/Vol2_Medical_Specialists_and_Physicians_Services_Handbook.pdf225 Texas Medicaid and Healthcare Partnership. Texas Medicaid Provider Procedures Manual (August 2012). Available at: http://www.tmhp.com/TMHP_File_Library/Provider_Manuals/TMPPM/2012/Aug2012_TMPPM.pdf226 Utah Division of Medicaid and Health Financing. Coverage and Reimbursement Code Lookup. Available at: http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php227 Utah Division of Medicaid and Health Financing. Utah Medicaid Provider Manual: Pharmacy Services. Available at:http://health.utah.gov/medicaid/manuals/pdfs/Medicaid%20Provider%20Manuals/Pharmacy/PHARMACY7-12.pdf228 Utah Division of Medicaid and Health Financing. Medicaid Provider Manual: CHEC Services (updated July 2010). Available at:http://health.utah.gov/medicaid/manuals/pdfs/Medicaid%20Provider%20Manuals/Child%20Health%20Evaluation%20And%20Care/CHEC7-10.pdf229 Utah Medicaid Program. 2011 Procedures Adult Criteria: Gastric Bypass Surgery. Available at:http://health.utah.gov/medicaid/pa/pdfs/Gastric_Bypass2011.pdf230 Department of Vermont Health Access, Agency of Human Services. 2012 Fee Schedules: CPT Codes (August 2012). Available at: http://dvha.vermont.gov/for-providers/2012-fee-schedules231 Vermont Department of Health, Agency of Human Services. Provider’s Toolkit. Available at: http://healthvermont.gov/family/toolkit/service.aspx232
Department of Vermont Health Access. Pharmacy Benefit Management Program Provider Manual 2012. Available at: http://dvha.vermont.gov/for-providers/12012-final-provider-manual-041812-clean-final.pdf233 Department of Vermont Health Access. Vermont Preferred Drug List (revised June 5, 2012). Available at: http://dvha.vermont.gov/for-providers/2012.06-vt-pdl-quicklist-vt-june-05-2012-final.pdf234 Department of Vermont Health Access. Bulletin No.11-03 (revised July 1, 2011). Available at: http://dvha.vermont.gov/budget-legislative/1vhap-limited-procedures-p4003.pdf
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235 Virginia Department of Medical Assistance Services. CPT Codes – Medical Procedures Billed by Physicians or Other Practitioners, Parts 1-4. Available at: http://www.dmas.virginia.gov/Content_pgs/pr-ffs.aspx236
Virginia Medicaid Program. Provider Manual: EPSDT. Supplement B (revised December 23, 2008). Available at: https://www.ecm.virginiamedicaid.dmas.virginia.gov/WorkplaceXT/getContent?vsId={6771991E-70C7-49C8-ABA6-E1E343D180F1}&impersonate=true&objectType=document&id={DBAF180B-7C26-440E-AD34-A9E21D329321}&objectStoreName=VAPRODOS1 pg.8237 Virginia Department of Medical Assistance Services. Pharmacy Services, Anti-Obesity Drug Prior-Authorization Criteria. Available at: https://www.virginiamedicaidpharmacyservices.com/documents/VAmps-FaxSAreq-WtLossCriteria-20100701.pdf238 Virginia Department of Medical Assistance Services. Physician/Practitioner Manual: Service Authorization Information. Appendix D (revised April 2012). Available at:https://www.ecm.virginiamedicaid.dmas.virginia.gov/WorkplaceXT/getContent?vsId={EA84D31F-39A3-459B-9F0B-F925CA3B040F}&impersonate=true&objectType=document&id={593CB8CF-5B47-40E1-AB6E-F8A62856B023}&objectStoreName=VAPRODOS1239 Virginia Department of Medical Assistance Services. Physician/Practitioner Manual: Service Authorization Information. Appendix D (revised April 2012). Available at:https://www.ecm.virginiamedicaid.dmas.virginia.gov/WorkplaceXT/getContent?vsId={E12C2049-2C84-4287-A165-65E855A68FFB}&impersonate=true&objectType=document&id={D53BE6D2-ACD5-4CAD-86BD-7324CF74CE7C}&objectStoreName=VAPRODOS1240Virginia Department of Medical Assistance Services. Physician/Practitioner Manual: Service Authorization Information. Appendix D (revised April 2012). Available at:https://www.ecm.virginiamedicaid.dmas.virginia.gov/WorkplaceXT/getContent?vsId={E12C2049-2C84-4287-A165-65E855A68FFB}&impersonate=true&objectType=document&id={D53BE6D2-ACD5-4CAD-86BD-7324CF74CE7C}&objectStoreName=VAPRODOS1241 Washington State Health Care Authority Medicaid. July 1, 2012 Physician and Related Services Fee Schedule (updated August 16, 2012). Available at: http://hrsa.dshs.wa.gov/rbrvs/#P242 Washington State Department of Social and Health Services, Health and Recovery Services Administration. Medical Nutrition Therapy: Fee Schedule and Policy Updates. Available at:http://hrsa.dshs.wa.gov/download/Memos/2008Memos/08-38.pdf243 Washington State Department of Social and Health Services, Health and Recovery Services Administration. Physician-Related Services: Early and Periodic Screening, Diagnosis and Treatment. Available at:http://hrsa.dshs.wa.gov/download/BillingInstructions/Physician-Related_Services_January_2010/Section_C.pdf244 Washington State Department of Social and Health Services, Health and Recovery Services Administration. Medicaid Provider Guide: A Guide to Prescription Drug Program (Refer to Chapter 182-530 WAC). Available at:http://hrsa.dshs.wa.gov/billing/documents/guides/prescription_drug_program_bi.pdf pg.C.4245 Washington State Department of Social and Health Services, Health and Recovery Services Administration. Physician-Related Services. Available at: http://hrsa.dshs.wa.gov/billing/documents/physicianguides/physician-related_services_mpg.pdf246 West Virginia Department of Health and Human Services, Bureau for Medical Services. WV Medicaid Physician’s Fee Schedule 2012. Available at: http://www.dhhr.wv.gov/bms/Pages/FeeSchedule.aspx247 West Virginia Department of Health and Human Services, Bureau for Medical Services. “Chapter 519 Covered Services, Limitations, and Exclusions for Practitioner Services, Including Physicians, Physician Assistants, andAdvanced Registered Nurse Practitioners, 519.17.” Provider Manual. Available at: http://www.dhhr.wv.gov/bms/Documents/manuals_Chapter_519_Practitioners.pdf248 West Virginia Department of Health and Human Services, Bureau for Medical Services. “Chapter 510: Covered Services, Limitations, and Exclusions for Hospital Services: Attachment I Special Coverage Considerationsand Billing Instructions.” Provider Manual. Available at: http://www.dhhr.wv.gov/bms/Documents/bms_manuals_Chapter_510_Hospital.pdf pg. 3-5249 Wisconsin ForwardHealth. Fee Schedule Search. Available at: https://www.forwardhealth.wi.gov/WIPortal/Max%20Fee%20Home/Max%20Fee%20Search/tabid/78/Default.aspx250 Wisconsin ForwardHealth. Physician Manual: Covered and Noncovered Medicine Services. Available at:https://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Display/tabid/152/Default.aspx?ia=1&p=1&sa=50&s=2&c=102&nt=Weight%20Management%20Services&adv=Y251 Wisconsin ForwardHealth. Pharmacy Manual: Prior Authorization, Services Requiring Prior Authorization. Available at:https://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Display/tabid/152/Default.aspx?ia=1&p=1&sa=48&s=3&c=11&nt=Prior%20Authorization%20for%20Anti-Obesity%20Drugs&adv=Y252 Wisconsin ForwardHealth. Physician Manual: Prior Authorization, Services Requiring Prior Authorization. Available at: https://www.forwardhealth.wi.gov/WIPortal/OnlineHandbooks/Display/tabid/152/Default.aspx?ia=1&p=1&sa=50&s=3&c=638&nt=Bariatric Surgery&adv=Y253 ACS Wyoming Medicaid. Procedure Code Search. Available at: http://wyequalitycare.acs-inc.com/fees/Fee_Schedule/index.asp254
ACS Wyoming Medicaid. Provider Manual: General Provider Information. §10.12.6 (revised July 2012). Available at: http://wyequalitycare.acs-inc.com/manuals/Manual_CMS-1500.pdf255 Wyoming Department of Health, Division of Healthcare Financing. Medicaid Pharmacy Provider Manual (revised December 1, 2011, version 12) Available at: http://www.wyequalitycare.org/uploads/vU/D-/vUD-BXeIN_UivW_UHPFVsg/Pharmacy-Manual-Dec_1_2011.pdf pg. 7256 ACS Wyoming Medicaid. Provider Manual: General Provider Information. §10.15.23.12 (revised July 2012). Available at: http://wyequalitycare.acs-inc.com/manuals/Manual_CMS-1500.pdf257 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.html258 Wilensky S, Whittington R and Rosenbaum S. Strategies for Improving Access to Comprehensive Obesity Prevention and Treatment Services for Medicaid-Enrolled Children. Washington: George WashingtonUniversity 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
