Utilization Review of Surgical Treatment of Morbid Obesity

BULLETIN 06-10 Date: May 22, 2006 To: Private Review Agents Re: Utilization Review of Surgical Treatment of Morbid Obesity COMAR 31.10.33 The purpose of this bulletin is to notify private review agents of new regulations that clarify the applicability of the National Institutes of Health’s guidelines to the utilization review process for surgical treatment of morbid obesity. The regulations were published in the Maryland Register on January 6, 2006 and finalized March 31, 2006, with an effective date of April 10, 2006. The regulations apply to private review agents who conduct utilization review for the surgical treatment of morbid obesity as a covered benefit under Insurance Article, §15-839, Annotated Code of Maryland. The new regulations set forth the criteria that may be applied by a private review agent when performing utilization review for the surgical treatment of morbid obesity. The regulations also establish acceptable documentation requirements for structured diet programs. A private review agent is required to limit the criteria to the permissible criteria listed in COMAR 31.10.33.03B and may not use any criteria that is more restrictive than the criteria listed in COMAR 31.10.33.03B. Also, a private review agent is required to accept any one of the items specified in COMAR 31.10.33.04B as acceptable documentation of completion of a structured diet program. If your organization conducts utilization review for patients covered under health benefit plans subject to §15-839 of the Insurance Article, your utilization review plan is required to be amended to conform to the new regulations. A copy of the specific criteria to be used in conducting utilization review for the surgical treatment of morbid obesity is required to be submitted to the Administration within 30 days of the date of this bulletin. Copies of the new regulations can be secured from the Division of State Documents website at www.dsd.state.md.us. Any questions about this bulletin or the new regulations should be directed to Ellen Woodall, Director, Managed Care Unit and PRA Unit, at (410) 468-2226. R. Steven Orr Insurance Commissioner By:______________________ Howard Max Associate Commissioner Life and Health Section R. STEVEN ORR Commissioner JAMES V. MCMAHAN, III Deputy Commissioner HOWARD MAX Associate Commissioner Life and Health ROBERT L. EHRLICH, JR. Governor MICHAEL S. STEELE Lt. Governor 525 St. Paul Place, Baltimore, Maryland 21202-2272 Direct Dial: 410-468-2205 Fax: 410-468-2204 Email: hmax@mdinsurance.state.md.us 1-800-492-6116 TTY: 1-800-735-2258 www.mdinsurance.state.md.us