Change in Criteria for Adolescent Bariatric Surgeries

Jul 28, 2023

Effective August 1, 2023, bariatric surgery centers that hold an accreditation from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) with Adolescent Qualification will no longer be required to seek a surgical recommendation by an endocrinologist for members under the age of 21. These same providers will no longer be required to seek recommendation by a second surgeon who is not affiliated with the first surgeon’s practices when providing Gastric Bypass, Gastroplasty Surgery, and Gastric Banding as described in the MaineCare Benefits Manual (MBM), Chapter II, Section 90, Physicians Services, 90.05-1(B)(2)(b) and (c). Bariatric surgery centers that hold this accreditation will still need to continue to submit a request for Prior Authorization (PA) that includes a recommendation by a primary care provider, and a licensed mental health provider specializing in children’s mental health as described in MBM, Chapter II, Section 90, Physicians Services, 90.05-1(B)(2)(a) and (d).    

Bariatric surgery centers that are not accredited under the MBSAQIP, or do not hold the Adolescent Qualification under this accreditation program, must continue to submit PA requests that meet all requirements outlined in MBM, Chapter II, Section 90.05-1(B)(2).    

The MaineCare supplemental criteria sheet has been updated on the HealthPas portal to reflect these changes. MaineCare may engage in rulemaking to update MBM Chapter II, Section 90.     

If you have any questions regarding bariatric surgeries provided to adolescent MaineCare members, please contact your Provider Relations Specialist, Shannon Beggs.