Patient Forms and Information - McLaren Port Huron

Patient forms and information for those having bariatric surgery

Steps Required Before Surgery at the Bariatric Center of Michigan

  1. Your Insurance Company: Check with your insurance company to see if bariatric surgery is a covered procedure. They will need the following information:
    • Diagnosis Code:
      • 278.01 (morbid obesity)
    • Procedure Code:
      • 43235 (esophagogastroduodenoscopy)
      • 43239 (esophagogastroduodenoscopy with biopsy)
      • 43644 (gastric bypass)
      • 43770 (gastric banding)
      • 43775 (gastric sleeve)
    • This is considered an inpatient surgery
  2. Financial/Insurance Consultation: A representative from McLaren Port Huron will contact you after your seminar attendance to review your insurance and any concerns regarding surgery.
  3. Letter from your Medical Doctor: A letter must be submitted to the Bariatric Center of Michigan stating any medical conditions caused by obesity (such as high blood pressure, diabetes, reflux, sleep apnea, osteoarthritis, urinary stress incontinence), a statement that you would benefit by this procedure (that is medically necessary), and that your physician is giving medical clearance for you to have surgery. This letter must include documentation that you have been clinically evaluated by an MD or DO who has documented failed weight loss. Some insurance companies require a structured, professionally or physician-supervised weight loss program for a minimum of 6 to 12 consecutive months prior to the recommendation for bariatric surgery.
    • Please mail or fax this letter to: McLaren Port Huron, Wismer 3rd Floor, 1221 Pine Grove Avenue, Port Huron, Michigan 48060; fax 810.987.1532.
    • If no pre-authorization is needed from your insurance company, all clearance letters, including those from your primary care provider and mental health provider, must be received at least 4 weeks prior to surgery. If pre-authorization is required, letters must be received at least 10 weeks prior to surgery. If letters are not received, surgery will be postponed.
  4. Behavioral Assessment: The Bariatric Center of Michigan can provide contact information for local agencies that can perform the assessment, or you may contact someone on your own. Check the cost of this service, as some insurance companies do not cover this service and prices will vary from office to office. This assessment will evaluate the understanding of lifestyle changes that occur with bariatric surgery.
  5. Nutritional Assessment: This must be performed at McLaren Port Huron by our dietitian, who is trained in special diet considerations for bariatric surgery patients. Two one-hour sessions will be scheduled prior to surgery. You will also meet with our dietitian after clinic visits throughout your first year. Other appointments may be scheduled on an as-needed basis following your surgery. For additional appointments or questions, call the McLaren Port Huron dietitian's office at 810.989.3321.
  6. Lab Work: An order for blood work will be given to you during your initial screening with the surgeon. Please follow the instructions given with this order. A second set of labs will be done to evaluate health status and must be completed within 30 days of surgery date.
  7. Sleep Study: The physician will evaluate the need for a sleep study and will discuss this with you. This may or may not be required.
  8. Additional clearances: may be required depending on health issues, and will be done at surgeon request.

Physician Supervised Weight Loss Program Documentation

    Request physician order form from the Bariatric Center of Michigan at 810.989.3328

Food and Exercise Log Instructions

    To meet insurance requirements for bariatric surgery, your insurance also requires a Food and Exercise Journal.

    See below for a description of how to keep a Food and Exercise Journal.

    Use any one of the following three choices:

    • Bariatric Center Food & Activity Diary form (see form example below) to record ALL food intake and activity.
    • Enter electronically using the journals available at www.myfitnesspal.com or www.sparkpeople.com.
    • Use the sample journal provided and write your daily food and exercise in a spiral notebook. Continue to keep the journal during your entire supervised weight loss journey.

    Journal entries must be printed and provided to the surgeon and the registered dietitian during your visits.

    The documentation required by your insurance provider cannot be changed by your primary care physician or your bariatric surgeon, even in cases where surgery is recommended by your physician(s) to correct other medical concerns.

    Please contact the Bariatric Center of Michigan at 810.989.3328 with any questions. We will be happy to help you.

Weekly Food Journal Example

    Weekly Food Journal - Week of:

    MEAL: SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
    BREAKFAST 2 scrambled eggs , 1Tbsp milk, 1 tsp Oil , 1 slice whole wheat toast, 1 tsp butter , 1/2 c. orange juice, 1 C coffee
    LUNCH 4 oz lean turkey, 2 slices whole wheat bread, 1 tsp mayo, 1 c. raw vegetables, 2 Tbsp ranch dressing, water
    DINNER 4 oz lean pork, 1/2 c. mashed potatoes, 1/2 c. green beans, 1 small dinner roll, 2 tsp butter, 1 C. skim milk
    SNACKS 15-20 Tortilla chips, 1/4c. Salsa, 1 Apple
    EXERCISE walked the dog - 30 minutes, washed the car - 45 minutes

Sample Letter for Primary Care Physician Clearance Letter Requirements

    Primary Care Physician: Please provide a medically cleared for surgery letter to include the following contents:

    Physician Name/Practice Letterhead

      To: (Patient’s surgeon of choice - Please choose one)
        Dr. Zubin Bhesania
        Dr. Karen McFarlane
        Dr. Anthony Boutt
      Attention: Wismer 3rd Floor
      1221 Pine Grove Avenue
      Port Huron, MI 48060
      Phone: 810.989.3328 Fax: 810.987.1532

    Necessary Information That Must Be Included In Letter:

    • Date
    • Mutual patient name
    • Mention that patient is requesting bariatric surgery
    • List of attempted weight loss strategies or methods
    • Length of time attempts have been made
    • Verification that patient has been on a medically supervised weight loss program for consecutive months (beginning date/ending date) without lasting effects
    • Provide documentation of clinic visits to support medically supervised weight loss
    • List of co-morbid conditions related to patient’s weight
    • List of current medications
    • Verification that patient understands the risks involved for bariatric surgery
    • Verification that patient is MEDICALLY CLEARED for surgery
    • Verification that the primary care provider believes that the patient would greatly benefit from bariatric surgery
    • Physician signature/date. Nurse practitioner/physician signature requires a co-signature from primary care provider

Psychiatric Assessment Requirements letter

    Bariatric Center of Michigan
    1221 Pine Grove Avenue
    Port Huron, MI 48060
    810.989.3328

    Dear Mental Health Provider,

    We are requesting a psychological assessment for our bariatric patient. This is a requirement for many insurance providers, and its purpose is: (1) to ensure that the patient is free from psychological factors that may interfere with good long-term results; and (2) assess the need for pre-surgical counseling.

    We understand that many tools are available, such as the Symptom Checklist-90 (SCL-90), Wahler Physical Symptoms Inventory (WPSI), and Personality Assessment Screen (PAS) to help evaluate the patient’s readiness for surgery. In short, the interview should include:

      a. Family weight and eating attitudes – to help identify influences that play in the family system.
      b. Daily food intake – identify snacking, temptations, and challenges in keeping up with eating three meals per day.
      c. Obesity and the body – personal, medical and physical challenges brought on by obesity.
      d. Commercial weight loss systems – successes and weight re-gain from those tried.
      e. Emotional ideation or suicidal thinking – triggered past experiences that have not been appropriately treated.
      f. Depression – was this related to their obesity or not?
      g. Substance abuse – including laxative abuse or other that have lead to hospitalization.
      h. Physical/sexual abuse – to help identify use as a protective mechanism.
      i. Supportive people – family and friends.
      j. Obstacles after surgery.

    The patient’s long term success and lifestyle change in his or her weight loss goals is our top priority. Please fax the completed letter to 810.987.1532. Thank you.
    Sincerely,

Psychiatric Assessment Requirements letter

  • Thomas Brozovich, D.O., McLaren Port Huron Outpatient Counseling
    (810) 984-5156
  • LIST Psychiatry, Bay City
    (989)790-3130
  • Note: You may choose any provider who is a licensed psychologist or Psychiatrist.