Bariatric Bypass Surgery

Member Information
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Member's ID#*
Member's DOB*
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Date of service (if known)
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Member's Name*
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Facility Information
Facility/Hospital NPI*

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Facility/Hospital name*
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Name of MD requesting surgery*
Phone #*
Fax #*
Contact Name*
Email address in order to receive confirmation of request receipt*

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Clinical Information
Type of request*
Type of request *
- Inpatient Services
- Outpatient Services
CPT Code(s) (Click + or - at the right to add up to 5 CPT Codes)*
CPT Code Units

Example CPT code: 12345
Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*
Diagnosis ICD 10 Diagnosis Code

Example ICD 10 Diag Code: Z87.890
Current BMI*
Height (Ex: 5’6”)*
Weight (in lbs)*
Describe impact on Activities of Daily Living:*
Describe co-morbid or other health conditions:*
Describe medically supervised weight loss attempts in last 6 months:*
Comment on demonstrated ability to comply with medical regimen:*
List any current psychiatric/psychosocial co-morbidities & treatment in place:*
Comment on ability to understand risk of gastric bypass surgery:*

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Attach Clinical*
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Signature of Treating Physician*
Signature Date*
Request Method*
Request Method *
- Standard
- Expedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.
  Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.
Attach additional Clinical documents for Expedited request*
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Signature of Physician or Licensed Provider (Required for Expedited request)*
Signature Date*
Comments
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CPT Code	Units

Diagnosis	ICD 10 Diagnosis Code

Member Information