31.10.33.03

.03 Utilization Review Criteria for Surgical Treatment of Morbid Obesity.

A. When establishing utilization review criteria for the surgical treatment of morbid obesity as a covered benefit under Insurance Article, §15-839, Annotated Code of Maryland, a carrier or a private review agent acting on behalf of a carrier:

(1) Shall limit the criteria to the permissible criteria listed in §B of this regulation; and

(2) May not use any criteria that is more restrictive to the member than the criteria listed in §B of this regulation.

B. Permissible Criteria for Utilization Review Decisions.

(1) Body Mass Index.

(a) Except as permitted under §B(1)(b) of this regulation, a carrier or a private review agent acting on behalf of a carrier shall consider a member to meet the body mass index criterion if the member has a body mass index greater than 40 kilograms per meter squared.

(b) If the member has a comorbid medical condition, the carrier or private review agent acting on behalf of the carrier may not impose the criterion described in §B(1)(a) of this regulation, but shall consider the member to meet the body mass index criterion if the member has a body mass index equal to or greater than 35 kilograms per meter squared.

(c) In determining whether the member has a comorbid medical condition under §B(1)(b) of this regulation, the carrier or the private review agent acting on behalf of the carrier shall consider the member to have a comorbid condition if the member has one of the following conditions:

(i) Hypertension;

(ii) A cardiopulmonary condition;

(iii) Sleep apnea;

(iv) Diabetes; or

(v) Any life threatening or serious medical condition that is weight induced.

(2) The carrier or private review agent acting on behalf of the carrier may establish a utilization review criterion that limits the benefit for surgical treatment of morbid obesity to adults who are 18 years old or older.

(3) The carrier or private review agent acting on behalf of the carrier may establish a utilization review criterion that requires the member to complete a psychological examination of the member's readiness and fitness for surgery and the necessary postoperative lifestyle changes before undergoing surgical treatment of morbid obesity.

(4) Completion of a Structured Diet Program.

(a) If a carrier or a private review agent acting on behalf of a carrier establishes a criterion that requires a member to complete a structured diet program, the carrier or private review agent acting on behalf of the carrier may not establish a criterion that is more restrictive than described in §B(4)(b) of this regulation.

(b) The carrier or the private review agent acting on behalf of the carrier shall consider the member to have completed a structured diet program, if the member completes either of the following in the 2-year period that immediately precedes the request for the surgical treatment of morbid obesity:

(i) One structured diet program for 6 consecutive months; or

(ii) Two structured diet programs for 3 consecutive months.

(c) A carrier or a private review agent acting on behalf of a carrier shall use flexibility with regard to defining a structured diet program.

(d) A carrier or a private review agent acting on behalf of a carrier shall consider commonly available diet programs, such as Weight Watchers or Jenny Craig, to be structured diet programs.