Anthem Blue Cross and Blue Shield
State Sponsored Business
Bariatric Surgery Physician Verification Form
In order to assist you in obtaining authorization for bariatric surgery we need clinical information to
support the medical necessity for this procedure. It is recommended you review the Anthem guidelines on
www.anthem.com. Please complete this form and attach the appropriate supporting
documentation. Once this form is completed and signed, please fax to 1-866-406-2803.
Member Information
Last Name:
First Name:
Anthem ID Number:
Date of Birth:
Date of Most Recent Medical Examination:
Height:
Weight:
BMI:
Date of BMI:
Co-Morbid Conditions:
Yes (if Yes, list below.)
1.
2.
3.
4.
No
Conservative Therapy
Date Started:
Date Ended:
Describe (attach additional pages if necessary):
Outcome:
Weight loss of
lbs. over
months
Explanation of member’s success or failure of conservative treatment:
Pre-Operative Medical Consultation
Performed on Date:
Result:
Acceptable for Bariatric Surgery
Not acceptable for Bariatric Surgery
Psychiatric Conditions
List those that would make it difficult for the member to understand, tolerate, and comply with all phases
of care and attach notes. If none identified, state “none”.
In Indiana, Anthem Insurance Companies Inc., dba Anthem Blue Cross and Blue Shield, is an independent licensee of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
0408 INW1233 04/18/08
State Sponsored Business, Anthem Blue Cross and Blue Shield
Bariatric Surgery Physician Verification Form
Page 2 of 2
Member Last Name:
Member First Name:
Pre-Operative Mental Health Assessment
Performed on Date:
Name of Mental Health Professional Performing Assessment:
Title of Mental Health Professional Performing Assessment:
Result:
Acceptable for Bariatric Surgery
Date member received information about the
reasonable outcomes of bariatric surgery
Not acceptable for Bariatric Surgery
Date member received a thorough explanation of
the risks, benefits, and uncertainties of the
procedure
Dietician/Nutritionist Evaluation
Please remember to attach evaluation.
Performed on Date:
Determination:
Acceptable for Bariatric Surgery
Not acceptable for Bariatric Surgery
Pre-operative dietary evaluations and nutritional counseling were performed on:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Post-operative dietary evaluations and nutritional counseling
are included in the treatment plan:
Yes
No
The current treatment plan includes counseling regarding
exercise, psychological issues, and the availability of supportive
resources when needed:
Yes
No
Proposed surgery with codes:
Gastric bypass length
cm
Codes:
Gastroplasty
Codes:
Biliopancreatic bypass with dudodenal switch
Codes:
Laparoscopic adjustable gastric banding
Codes:
I do attest that the above is true and accurate to the best of my knowledge.
Print Physician Name:
Physician Signature*:
Date:
* The physician performing the surgery must sign this form. Stamped signatures
will not be accepted.