Alabama Medicaid Agency Nutritional Assessment/Counseling, Pharmaceutical Therapy Bariatric Surgery Adults: authorization required. PA requirements not Prior authorization required. Medicaid does not cover dietitians except for recipients specified beyond PA form. under 21 years of age. Must be within 18 and 64 years of age. Must meet Xenical is the only currently covered. specific medical criteria and PA or the surgery will be CPT Codes: 99401-99402 considered cosmetic and will not be covered by To receive prior authorization for Xenical®, the patient Medicaid. EPSDT: must be 18 years of age or older and have at least one of Diet instruction performed by a physician is considered the following primary medical diagnoses: Specific prior authorization criteria not found. part of a routine visit Diabetes mellitus Hypertension EPSTD screenings will be covered only if the provider is Hyperlipidemia enrolled in that program. Screenings are not subjected to prior authorization. Renewal requests require the patient’s previous and current weights (in pounds). Continued weight loss must be documented for renewals. There must be documentation in the patient record to support failure with prior physician supervised exercise/diet regimen(s) of at least 6 months duration. Documentation must also show that adjuvant therapy is planned. Medical justification may include peer-reviewed literature, medical record documentation, or other information specifically requested. Approval may be for up to 3 months with initial request, and up to 6 months for each subsequent request to a total approval period not to exceed 2 years for the recipient.
Alabama Medicaid Agency Nutritional Assessment/Counseling, Pharmaceutical Therapy Bariatric Surgery Adults: Medicaid does not cover dietitians except for recipients under 21 years of age. CPT Codes: 99401-99402 EPSDT: Diet instruction performed by a physician is considered part of a routine visit EPSTD screenings will be covered only if the provider is enrolled in that program. Screenings are not subjected to prior authorization. authorization required. PA requirements not specified beyond PA form. Xenical is the only currently covered. To receive prior authorization for Xenical®, the patient must be 18 years of age or older and have at least one of the following primary medical diagnoses: Diabetes mellitus Hypertension Hyperlipidemia Renewal requests require the patient’s previous and current weights (in pounds). Continued weight loss must be documented for renewals. There must be documentation in the patient record to support failure with prior physician supervised exercise/diet regimen(s) of at least 6 months duration. Documentation must also show that adjuvant therapy is planned. Medical justification may include peer-reviewed literature, medical record documentation, or other information specifically requested. Approval may be for up to 3 months with initial request, and up to 6 months for each subsequent request to a total approval period not to exceed 2 years for the recipient. Prior authorization required. Must be within 18 and 64 years of age. Must meet specific medical criteria and PA or the surgery will be considered cosmetic and will not be covered by Medicaid. Specific prior authorization criteria not found.