Nebraska Department of Health and Human Services,
Division of Medicaid and Long Term Care
Bariatric Surgical Checklist:
BARIATRIC SURGICAL PROCEDURE PRIOR AUTHORIZATION
REVIEW CHECKLIST
REQUIRED INFORMATION TO BE PROVIDED BY THE BARIATRIC SURGEON
Current history and physical that includes the client’s:
 Name
 Date of birth
 Primary diagnosis
 Co-morbidities
Referral from primary care physician, which must include:
 Reason why primary care physician is making the referral
 Medical diagnoses (diabetes, cardio-pulmonary conditions, hypertensions, sleep
apnea, etc.)
NOTE: OBESITY BY ITSELF IS NOT CONSIDERED A REFERRAL DIAG NOSIS
Plan of care from the bariatric center, which must include:
 How long the bariatric center will provide direct follow-up with the patient
 What specific follow-up will be addressed (dietary counseling and support,
medical care related to the surgery, etc.)
 What communication will go to the PCP when this direct follow-up ceases
 What management support will be provided to the PCP in caring for the patient
Evidence of treatment/management of BMI 35 or greater, with one of the following comorbidities:
 DM type II (include recent lab results and current medications)
 Hypertension (include current medications/antihypertensive and BP readings)
 CAD/CHF/dyslipidemia (include recent lab results and current medications)
BARIATRIC SURGICAL PROCEDURE PRIOR AUTHORIZATION
REVIEW CHECKLIST Continued…
Nebraska Department of Health and Human Services,
Division of Medicaid and Long Term Care
Bariatric Surgical Checklist:
REQUIRED INFORMATION TO BE PROVIDED BY THE BARIATRIC
SURGEON
 Obstructive sleep apnea (include sleep study results and current treatment)
 GERD/reflux (include test results and current medications being used to manage
the symptoms)
 Osteoarthritis (include information about the client’s ability to ambulate, assistive
devices used and
 any medications being used to manage symptoms)
 Pseudotumor cerebri (include diagnostic reports/imaging)
 Pre-operative evaluations must include:
 Cardiac and pulmonary evaluations if existing cardio-pulmonary co-morbidities
(provide all related consults)
 Dietary consultation, including documentation of a supervised diet program for
six months or more and
 determination that the patient is motivated to comply with dietary changes
 Psychiatry/psychology consultation that includes evaluation to determine
readiness for surgery and
 lifestyle changes as well as:
 No behavior health disorder by history and physical exam
 Behavioral health disorder by history and physical exam, that includes:
 No severe psychosis/personality disorder
 Mood/anxiety disorder excluded/treated (if treated, include treatment
medications/modalities)
 Endocrinopathy (hypothyroid or Cushing’s syndrome)excluded
 If any GI symptoms, active peptic ulcer disease excluded by testing
 Include EGD/UGI results
 H. pylori negative or treated
 Include dates of treatment
 Drug/alcohol screen
 No drugs or alcohol by history
 Alcohol- and drug-free for a period of one year or greater
 Smoking cessation is attempted
 Procedure performed at facility that is a Bariatric Surgery Center of Excellence
 Patient understanding of surgical risk, post procedure compliance and follow -up