Adults: Not explicitly mentioned. Excluded drugs include: Requires authorization. Anorexics Medicaid does not reimburse for – CPT Codes: 96150-96155, 97802-97804 anorexics with the exception of orlistat; Louisiana Medicaid covers bariatric or weight loss surgery as an option only after a comprehensive and EPSDT: Medicaid will provide reimbursement to outpatient sustained program of diet and exercise with or without Obesity services outside of mandated EPSDT services pharmacies for orlistat prescriptions based on the pharmacologic measures has been unsuccessful over are not explicitly mentioned. following criteria: time. Bariatric surgery may consist of open or An authorized prescriber has hand written the laparoscopic procedures that revise the gastro-intestinal prescription - no facsimiles allowed; anatomy to restrict the size of the stomach and/or reduce Patient is twelve years of age or older; absorption of nutrients. Only original prescriptions—no refills are allowed; Maximums of ninety (90) capsules and thirty (30) Authorization: Surgeons who perform bariatric days supply; surgery must obtain prior authorization through the fiscal Patient has a documented current body mass index intermediary’s Prior Authorization (PA) Unit. The PA (BMI) of twenty-seven (27) or greater and the request shall include a thorough multidisciplinary prescriber had identified the BMI, in his/her evaluation within the previous 12 months. handwriting, on the dated prescription or a dated and signed attachment to the prescription; NOTE: A physician letter documenting recipient Patient has other risk factors warranting the use of qualifications and medical necessity must accompany the Orlistat and the prescriber has identified an approved PA request and must include confirmatory evidence of ICD-9-CM diagnosis code in his/her handwriting, on co-morbid condition(s). Photographs must be the dated prescription or a dated and signed submitted with the request for consideration of attachment to the prescription; and bariatric surgery. No provisions for override of the prospective drug utilization edits, i.e., early refill (ER) and duplicate drug (ID) editing. Refer to source for full criteria
Adults: Not explicitly mentioned. CPT Codes: 96150-96155, 97802-97804 EPSDT: Obesity services outside of mandated EPSDT services are not explicitly mentioned. Excluded drugs include: Anorexics – Medicaid does not reimburse for anorexics with the exception of orlistat; Medicaid will provide reimbursement to outpatient pharmacies for orlistat prescriptions based on the following criteria: An authorized prescriber has hand written the prescription - no facsimiles allowed; Patient is twelve years of age or older; Only original prescriptions—no refills are allowed; Maximums of ninety (90) capsules and thirty (30) days supply; Patient has a documented current body mass index (BMI) of twenty-seven (27) or greater and the prescriber had identified the BMI, in his/her handwriting, on the dated prescription or a dated and signed attachment to the prescription; Patient has other risk factors warranting the use of Orlistat and the prescriber has identified an approved ICD-9-CM diagnosis code in his/her handwriting, on the dated prescription or a dated and signed attachment to the prescription; and No provisions for override of the prospective drug utilization edits, i.e., early refill (ER) and duplicate drug (ID) editing. Refer to source for full criteria Requires authorization. Louisiana Medicaid covers bariatric or weight loss surgery as an option only after a comprehensive and sustained program of diet and exercise with or without pharmacologic measures has been unsuccessful over time. Bariatric surgery may consist of open or laparoscopic procedures that revise the gastro-intestinal anatomy to restrict the size of the stomach and/or reduce absorption of nutrients. Authorization: Surgeons who perform bariatric surgery must obtain prior authorization through the fiscal intermediary’s Prior Authorization (PA) Unit. The PA request shall include a thorough multidisciplinary evaluation within the previous 12 months. NOTE: A physician letter documenting recipient qualifications and medical necessity must accompany the PA request and must include confirmatory evidence of co-morbid condition(s). Photographs must be submitted with the request for consideration of bariatric surgery.