Anthem Blue Cross Blue Shield Partnership Plan, Inc.
State Sponsored Business
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- 888-209-7838.
Member Information
Last Name: First Name:
Anthem ID Number:
Date of Most Recent Medical Examination:
Date of Birth:
Height:
BMI:
Weight:
Date of BMI:
Co-Morbid Conditions: Yes (if Yes, list below.)
1. 2.
No
3. 4.
Conservative Therapy
Date Started:
Describe (attach additional pages if necessary):
Date Ended:
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 Ohio, Anthem Blue Cross Blue Shield Partnership Plan, Inc. 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.
1007 OHW1223 12/26/07

State Sponsored Business, Anthem Blue Cross Blue Shield Partnership Plan, Inc.
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 Not acceptable for Bariatric Surgery
Date member received information about the reasonable outcomes of 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:
The current treatment plan includes counseling regarding exercise, psychological issues, and the availability of supportive resources when needed:
Proposed surgery with codes:
Gastric bypass length cm
Yes
Yes
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:
No
No
Physician Signature*:
Date:
* The physician performing the surgery must sign this form. Stamped signatures will not be accepted.