Stepwise, Goal-directed, Educationally-reinforced Healthy Lifestyle Modification and Weight Management Success Coaching Programs

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PWMS Bariatric Surgery Ready for Success™ Program

This is a summary of the major insurance companies’ and Medicare’s (CMS) requirements for a physician directed, professionally-supervised weight management and diet program for 6 months within the one to two years prior to surgery for weight loss. For a detailed list of qualification criteria, please contact your insurance company. These preliminary requirements only apply if the weight loss surgery is a covered benefit under the patient’s (or your) insurance policy. Some healthcare policies will have exclusions thus making your insurance coverage ineligible for these services.

Participation in the PWMS Bariatric Surgery Ready for Success ™ Program helps its participants prepare for weight control success, pre-qualify for bariatric or weight loss surgery coverage, and meet the stringent clinical documentation requirements (please read below) established by most major insurance providers, including Medicare and Medicaid, to qualify as a physician directed, medically-supervised weight management and diet program.

  • Documentation of diagnosis as morbidly obese for three or four of the previous five years
  • Documentation of a physician supervised weight management program to include:
    • low calorie structured diet [1000 – 1200 calories]
    • lifestyle/behavior modification coaching intervention
    • increased aerobic physical activity
    • all clinically documented in the medical record for at least 6 months within the past 2 years (3 of the 6 months must be consecutive)
    • nutritional counseling consultation with a registered dietician at some point during the program
    • Psychological evaluation to assess compliance and understanding of surgical risk, benefits and alternatives for weight management success should be performed, prior to bariatric surgery pre-certification and pre-approval
  • Documentation of consideration or use of pharmacotherapy with a FDA-approved medication, if appropriate
  • For Medicare, Medicaid, and most major healthcare insurance provider patients, there should be documented evidence of repeated failure of multiple attempts (usually 2 to 3) to lose weight on a supervised non-surgical management weight loss program (e.g., diet, exercise or drugs) in the medical records
  • It is expected that one of the weight loss programs would consist of compliance with a physician directed/clinically-supervised program for at least a consecutive 6 month period without significant gaps
  • Documentation should include medical records of the physician’s initial assessment of the member, and the physician’s exit assessment of the member’s progress at the completion of the program
  • Must show treatment of morbid obesity that has not responded to conservative measures
  • However, diet programs/plans alone, such as Weight Watchers, Jenny Craig and similar plans, are not considered physician directed weight management programs and do not meet this pre-qualification requirement as defined by the Centers for Medicare and Medicaid (CMS) and the majority of major insurers
  • Similarly, physician directed programs consisting exclusively of pharmacological management are not sufficient to qualify and meet this physician-supervised weight management program requirement
All Medicare & Medicaid claims for any procedure for bariatric surgery for morbid obesity must be supported by accurate clinical documentation in the medical record and include the following information:
  • History and physical containing evidence of co-morbid medical conditions
  • 6-months of office/progress notes documenting attempts of non-surgical methods of weight loss
  • Consultant reports documenting psychological evaluation and nutritional counseling
  • These reports must be available to Medicare (CMS) and/or the Insurance Company upon request

Am I a PWMS Program Candidate?

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