SECTION 317:30-5-137.1. Member candidacy

  Documentation must be submitted to the OHCA prior authorization unit prior to beginning any treatment program to ensure all requirements are met and the member is an appropriate candidate for bariatric surgery. This is the first of two prior authorizations required to approve a member for bariatric surgery. To be considered, members must meet the following candidacy criteria:

(1)   be between 18 and 65 years of age;

(2)   have body mass index (BMI) of 35 or greater;

(3)   be diagnosed with one of the following:

(A)   diabetes mellitus;

(B)   degenerative joint disease of a major weight bearing joint(s). The member must be a candidate for joint replacement surgery when optimal weight loss is achieved; or

(C)   a rare co-morbid condition in which there is medical evidence that bariatric surgery is medically necessary to treat such a condition and that the benefits of bariatric surgery outweigh the risk of surgical mortality.

(4)   have presence of obesity that has persisted for at least 5 years;

(5)   have attempted weight loss in the past without successful long term weight reduction, which must be documented by a physician;

(6)   have absence of other medical conditions that would increase the member's risk of surgical mortality or morbidity; and

(7)   the member is not pregnant or planning to become pregnant in the next two years.

[Source: Added at 27 Ok Reg 450, eff 12-3-09 (emergency); Added at 27 Ok Reg 939, eff 5-13-10]