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What documentation is required to be in the chart of patients undergoing weight loss surgery to show they have participated in a supervised weight loss program?

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What documentation is required to be in the chart of patients undergoing weight loss surgery to show they have participated in a supervised weight loss program?

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We would expect that the medical record reflect at least three failed attempts to lose weight on a supervised non-surgical weight loss program of which one of these attempts having been a physician directed program for at least 6 consecutive months (with corresponding monthly notes that included the assessments as follows and as itemized in the each state’s local coverage decision): -Vital signs to include weight – Current dietary program – Physical activity/exercise program – Behavioral interventions – Consideration of or use of pharmacotherapy with FDA-approved medication, if appropriate We’d expect that the physician directed program would have recently preceded (i.e. no more than 12-18 months before) the referral to surgical treatment. Please closely review the policy for all requirements: TN policy: http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=24057&lcd_version=5&show=all NC policy: http://www.cms.hhs.gov/MCD/viewlcd.asp?lcd_id=23540&lcd_version=3&basket=lcd%3A23540%3A3%3ABariatr

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