831-00057-03 (02/18) © 2014 – 2018 Security Health Plan of Wisconsin, Inc. Effective 6/2014
• Poorly controlled diabetes mellitus while compliant with appropriate medications .........l Yes l No
• Poorly controlled hypertension while compliant with appropriate medications .............l Yes l No
• HgbA1c equal to or greater than 7 (minimum of 2 readings 3 months apart) ................l Yes l No
• While taking at least two oral medications OR taking insulin ..............................l Yes l No
• While taking at least two oral medications ...............................................l Yes l No
• Blood pressure greater than or equal to 140/90 mm hg ...................................l Yes l No
Member has been free of illicit drug use and alcohol abuse or dependence
for the 6 months prior to surgery .............................................................l Yes l No
Member has been obese for at least 5 years ...................................................l Yes l No
Member has not had bariatric surgery before or there is clear evidence of
compliance with dietary modification and supervised exercise, including
appropriate lifestyle changes, for at least 2 years ..............................................l Yes l No
Member has been evaluated for adequacy of prior efforts to lose weight.
If there have been no or inadequate prior dietary efforts, the member must undergo
6 months of a medically-supervised weight reduction program .................................l Yes l No
Member has had a medical evaluation from the member’s primary care physician,
assessing preoperative condition and surgical risk and finding the member
to be an appropriate candidate ...............................................................l Yes l No
Member has received a preoperative evaluation by an experienced and knowledgeable
multi-disciplinary bariatric treatment team composed of health care providers
with medical, nutritional, and psychological experience:
A complete history and physical examination, specifically evaluating for
obesity-related comorbidities that would require preoperative management .................l Yes l No
Evaluation for any correctable endocrinopathy that might contribute to obesity ..............l Yes l No
Psychological or psychiatric evaluation to determine appropriateness for surgery ............l Yes l No
For members receiving active treatment for a psychiatric disorder, an evaluation
by his or her treatment provider prior to bariatric surgery. The treatment provider
must clear the member for bariatric surgery ...............................................l Yes l No
At least 3 consecutive months of participation in a weight management program prior to the
date of surgery, including dietary counseling, behavioral modification, and supervised exercise, in
order to improve surgical outcomes, reduce the potential for surgical complications, and establish
the candidate’s ability to comply with postoperative medical care and dietary restrictions.
Name of Program(s)
Start Date/End Date
of Program
Indicate Weight Gain or
Loss and Number of Pounds
Start date End date
____________ ____________
l Weight gain
l Weight loss
________ pounds
Start date End date
____________ ____________
l Weight gain
l Weight loss
________ pounds
Start date End date
____________ ____________
l Weight gain
l Weight loss
________ pounds
Start date End date
____________ ____________
l Weight gain
l Weight loss
________ pounds
Start date End date
____________ ____________
l Weight gain
l Weight loss
________ pounds
