12/12/17. I. Request is for any of the following routine bariatric surgery procedures must satisfy any of the following: A-D

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1 Reference #: MC/H003 Page 1 of 13 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan (PCHP) PreferredOne Insurance Company (PIC) Individual PreferredOne Insurance Company (PIC) Large Group PreferredOne Insurance Company (PIC) Small Group Please refer to the member s benefit document for specific information. To the extent there is any inconsistency between this policy and the terms of the member s benefit plan or certificate of coverage, the terms of the member s benefit plan document will govern. Benefits must be available for health care services. Health care services must be ordered by a physician, physician assistant, or nurse practitioner. Health care services must be medically necessary, applicable conservative treatments must have been tried, and the most cost-effective alternative must be requested for coverage consideration. Plans may have access restrictions for bariatric surgery. PURPOSE: The intent of this criteria document is to ensure services are medically necessary. GUIDELINES: Medical Necessity Criteria must satisfy I, and any of the following: II-VI I. Request is for any of the following routine bariatric surgery procedures must satisfy any of the following: A-D A. Biliopancreatic Diversion with Duodenal Switch (BPD/DS), open or laparoscopic B. Laparoscopic Adjustable Gastric Banding (such as, but not limited to, LAP-BAND, Realize Personalized Banding Solution, Swedish Adjustable Gastric Banding [SAGB]) C. Roux-en-Y Gastric Bypass (RYGB), open or laparoscopic D. Sleeve Gastrectomy, open or laparoscopic II. Requests for initial bariatric surgery for members 18 years of age or older must satisfy one of the following: A or B A. Initial bariatric surgery is being done at a designated participating bariatric surgery program accredited through Metabolic and Accreditation and Quality Improvement Program (MBSAQIP) (see Attachment A for a list of the designated participating bariatric surgery programs that meet this criteria); or B. Initial bariatric surgery is not being done at a designated participating bariatric surgery program must satisfy all of the following: 1-4 [Note: Not covered for plans which require bariatric surgery to be performed by a designated participating bariatric surgery program.] 1. Any of the following: a-c a. BMI of 60kg/m 2 or greater requesting two stage bariatric operations require a review of the medical literature to determine if the proposed procedure is investigative, benefits must be checked carefully to determine if two procedures would be allowed; or

2 Reference #: MC/H003 Page 2 of 13 b. BMI greater than 40kg/m 2 (greater than 55 for a proposed biliopancreatic diversion/duodenal switch); or c. BMI between 35 and 40kg/m 2 with any of the following obesity related medical conditions that have not responded to medical treatment: i-ix i. Sleep apnea ii. Pickwickian syndrome iii. Cardiac compromise iv. Diabetes mellitus v. Hypertension vi. Osteoarthritis of weight bearing joints exacerbated by obesity vii. Gastroesophageal reflux disease (GERD) viii. Dyslipidemia ix. Pseudotumor cerebri 2. BMI of 35kg/m 2 or greater for at least the past three years. 3. Documentation of active participation in a medically-supervised non-surgical weight loss plan during the last year to demonstrate member s ability to comply with post-operative dietary and lifestyle changes for weight loss maintenance. Must satisfy both of the following: a and b a. Documentation requirements - all of the following: i-iii i. Member s participation is documented in the member s medical records by the medical professional who supervised the member s progress in the non-surgical weight loss plan; and ii. Demonstrates member s compliance with the non-surgical weight loss plan (including at least six monthly visits over six consecutive months with the supervising medical professional); and iii. Includes supervising medical professional s recommendations/changes to the non-surgical weight loss plan throughout its course. b. Non-surgical weight loss plan requirements both of the following: i and ii i. Supervised by any of the following medical professionals: a)-e) a) Medical Doctor (MD or DO) b) Physician s Assistant (PA) c) Nurse Practitioner (NP) d) Clinical Nurse Specialist (CNS) e) Registered dietitian supervised by an MD, DO, PA, NP, or CNS. ii. Integrated components include diet, exercise, behavior modification, and pharmacological management. 4. Documentation of all of the following: a-c a. A comprehensive preoperative medical history and physical examination; and b. A preoperative psychosocial evaluation - must satisfy both of the following: i and ii i. To ensure the absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations; and ii. For members who have a history of severe psychiatric disturbance (chemical dependency, schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, preoperative psychological clearance is necessary to ensure members are able to provide informed consent and are able to comply with the pre-and post-operative regimen (the presence of depression due to obesity is not normally considered a contraindication to obesity surgery).

3 Reference #: MC/H003 Page 3 of 13 c. The physician requesting authorization for the surgery must confirm that the member s treatment plan includes a surgical preparatory program addressing all the following components in order to improve outcomes related to the surgery and that the member is able to comply with post-operative medical care and dietary restrictions all of the following: i-iv i. Pre-operative and post-operative dietary plan; and ii. Behavior modification strategies; and iii. Counseling instruction on exercise and increased physical activity; and iv. Ongoing support for lifestyle changes necessary to make and maintain appropriate choices that will reduce health risk factors and improve overall health. III. Requests for initial bariatric surgery for adolescents who have attained Tanner 4 or 5 pubertal development (see Attachment C) or have a bone age of greater than or equal to 13 years in girls or 15 years in boys - must satisfy: A or B, and C [Note: Requests for adolescents who have not yet completed bone growth will be assessed on a case-by-case basis.] A. Initial bariatric surgery is being done at a designated participating bariatric surgery program accredited through MBSAQIP as a with Qualifications or as an Center (see Attachment A); or B. Initial bariatric surgery is not being done at a designated participating bariatric surgery program must meet: 1 or 2, and all of 3-5 [Note: Not covered for plans which require bariatric surgery to be performed by a designated participating bariatric surgery program.] 1. BMI is greater than or equal to 40kg/m 2 ; or 2. BMI is greater than or equal to 35kg/m 2 with any of the following obesity related medical conditions that have not responded to medical treatment: a-g a. Hypertension b. Type 2 diabetes mellitus and either of the following: i or ii i. Insulin resistance; or ii. Glucose intolerance c. Substantially impaired quality of life or activities of daily living d. Dyslipidemia e. Pseudotumor cerebri f. Severe nonalcoholic steatohepatitis (NASH) g. Sleep apnea with apnea-hypopnea index > 5 3. Program has significant experience with adolescents; and 4. Documentation of active participation in a medically-supervised non-surgical weight loss plan during the last year to demonstrate member s ability to comply with post-operative dietary and lifestyle changes for weight loss maintenance - must satisfy both of the following: a and b a. Documentation requirements all of the following: i-iii i. Member s participation is documented in the member s medical records by the medical professional who supervised the member s progress in the non-surgical weight loss plan; and ii. Demonstrates member s compliance with the non-surgical weight loss plan (including at least six monthly visits over six consecutive months with the supervising medical professional); and

4 Reference #: MC/H003 Page 4 of 13 iii. Includes supervising medical professional s recommendations/changes to the non-surgical weight loss plan throughout its course. b. Non-surgical weight loss plan requirements both of the following: i and ii i. Supervised by any of the following medical professionals: a)-e) a) Medical Doctor (MD or DO) b) Physician s Assistant (PA) c) Nurse Practitioner (NP) d) Clinical Nurse Specialist (CNS) e) Registered dietitian supervised by an MD, DO, PA, NP, or CNS ii. Integrated components include diet, exercise, behavior modification, and pharmacological management. 5. Documentation of all of the following: a-c a. A comprehensive preoperative medical history and physical examination; and b. A preoperative psychosocial evaluation by a psychologist, psychiatrist, or other qualified independently licensed provider with specific training and credentialing in pediatric and adolescent care must satisfy both of the following: i and ii i. To ensure the absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations; and ii. For members who have a history of severe psychiatric disturbance (chemical dependency, schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, preoperative psychological clearance is necessary to ensure members are able to provide informed consent and are able to comply with the pre-and post-operative regimen (the presence of depression due to obesity is not normally considered a contraindication to obesity surgery). c. The physician requesting authorization for the surgery must confirm that the member s treatment plan includes a surgical preparatory program addressing all the following components in order to improve outcomes related to the surgery and that the member is able to comply with post-operative medical care and dietary restrictions must satisfy all of the following: i-v i. Pre-operative and post-operative dietary plan; and ii. Behavior modification strategies; and iii. Counseling instruction on exercise and increased physical activity; and iv. Ongoing support for lifestyle changes necessary to make and maintain appropriate choices that will reduce health risk factors and improve overall health; and v. The adolescent member has a committed family. C. The adolescent member does not have any of the following: Unresolved eating disorder; or 2. Untreated psychiatric disorder; or 3. Prader-Willi syndrome.

5 Reference #: MC/H003 Page 5 of 13 IV. Conversion of bariatric surgery to another routine bariatric surgery (I. above) - must satisfy: A and B, and one of C or D A. Coverage for bariatric surgery is available under the member s current health care plan; and B. If required by plan language, surgery is being performed at a designated participating bariatric surgery program accredited through MBSAQIP; and C. Failure to respond to initial bariatric surgery must satisfy all of the following: Initial bariatric surgery was at least 2 years prior to repeat procedure; and 2. Excess body weight loss has been less than 50%; and 3. Member is currently greater than 30% above ideal body weight (defined as maximum BMI of 24.9 m 2 ); and 4. Documentation that member has been enrolled in and compliant with the previous post-operative program. D. To treat complications related to surgery must satisfy both of the following: 1 and 2 1. Documentation of surgical complication/s from the initial bariatric surgery (such as, but not limited to, gastric pouch dilation, fistula, staple line breakdown, stoma dilation or stenosis, stoma ulcer, malabsorption, malnutrition, mechanical obstruction); and 2. Documentation that member has been enrolled in and compliant with the previous post-operative program. V. Revision of bariatric surgery must satisfy A and one of the following: B or C A. If required by plan language, surgery is being performed at a designated participating bariatric surgery program accredited through MBSAQIP; and B. Replacement of an implanted device (such as, but not limited to, gastric band) due to complications or malfunctions (such as, but not limited to, port leakage, migration/slippage, erosion in band area, concentric dilatation, and esophageal dilatation) that cannot be corrected with band manipulation or adjustments; or C. Revision of an initial bariatric procedure to treat complications related to surgery all of the following: Initial bariatric surgery was successful in inducing weight loss (excess body weight loss has been greater than or equal to 50%); and 2. Documentation of surgical complication/s from the initial bariatric surgery (such as, but not limited to, gastric pouch dilation, fistula, staple line breakdown, stoma dilation or stenosis, stoma ulcer, malabsorption, malnutrition, mechanical obstruction); and 3. Documentation that member has been enrolled in and compliant with the previous post-operative program. VI. Reversal (takedown) of bariatric surgery - Must have documented surgical complications from the initial bariatric surgery (such as, but not limited to, gastric pouch dilation, fistula, staple line breakdown, stoma dilation or stenosis, stoma ulcer, malabsorption, malnutrition, mechanical obstruction or migration of lap band).

6 Reference #: MC/H003 Page 6 of 13 DEFINITIONS: Body Mass Index (BMI): Determined by weight (kilograms)/height (meters) 2 Conversion of bariatric surgery: Change from one type of bariatric procedure to a different bariatric procedure (such as, but not limited to, conversion from a vertical gastric band to a Roux-en-Y). Ideal body weight: BMI between 18.5 and 24.9 m 2 Revision of bariatric surgery: To restore the effectiveness of the original bariatric surgery Reversal (Takedown) of bariatric surgery: Reverse the anatomic changes from the initial bariatric surgery BACKGROUND: This criteria document is based on expert professional practice guidelines and/or reliable evidence. It is the expectation that an appropriate medical evaluation to rule out treatable medical conditions that may be causing the obesity has been done before proceeding with bariatric surgery. Coverage of bariatric surgery is driven by benefit plan language. Some Plans require bariatric surgery (includes initial surgery and revision or conversion) to be performed by a designated participating bariatric surgery program. Programs that are in network (both facility and provider) for the member and accredited as a Low Acuity Center, a, a with Qualifications, or an Center through the Metabolic and Accreditation and Quality Improvement Program (MBSAQIP), a joint program of the American College of Surgeons and the American Society for Metabolic and Bariatric Surgeons, are considered designated participating bariatric surgery programs. See Attachment A for a list of designated participating bariatric surgery programs in the states of Iowa, Minnesota, North Dakota, South Dakota, and Wisconsin. The accuracy of designated participating bariatric surgery programs listed in Attachment A applies only to the Accessed Date. For the most current list of designated participating bariatric surgery programs, including programs outside the five aforementioned states, please visit: Attachment D is an Overview of the Designation Levels and Award Definitions. To view the full Standards outlining Optimal Care of the Metabolic and Patient, please access the most recent MBSAQIP Standards Manual.

7 Reference #: MC/H003 Page 7 of 13 FOR INTERNAL USE ONLY COVERAGE: Prior Authorization: Yes Coverage is subject to the member s contract benefits. CODING: CPT Laparoscopy, surgical, gastric restrictive procedure, with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150cm or less) Laparoscopy, surgical, gastric restrictive procedure, with gastric bypass and small intestine reconstruction to limit absorption Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band or subcutaneous port components) Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150cm or less) Roux-en-Y gastroenterostomy Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device Gastric restrictive procedure, open; revision of subcutaneous port component only Gastric restrictive procedure, open; removal of subcutaneous port component only Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only CPT codes copyright 2017 American Medical Association. All Rights Reserved. CPT is a trademark of the AMA. The AMA assumes no liability for the data contained herein. RELATED CRITERIA/POLICIES: Process Manual: UR015 Use of Medical Policy and Criteria Medical Policy: MP/C009 Coverage Determination Guidelines Medical Policy: MP/I001 Investigative Services REFERENCES: 1. Clinical Issues Committee of the American Society for Metabolic and. Updated Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. Surgery for Obesity and Related Diseases. 8 (2012) e21-e26. Revised March 14, Retrieved from Acessed 09/19/17.

8 Reference #: MC/H003 Page 8 of Omana JJ, Nguyen SQ, Herron D, Kini S. Comparison of comorbidity resolution and improvement between laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding. Surg Endosc Mar SAGES. Guidelines for clinical application of laparoscopic bariatric surgery Retrieved from Accessed on September 19, Michalsky M, Reichard K, Inge T, Pratt J, Lenders C. ASMBS pediatric committee best practice guidelines. Surgery for Obesity and Related Diseases, doi: /j.soard Pratt JSA, Lenders CM, Dionne EA, Hoppin AG, Hsu GLK, Inge TH, et al. Best practice updates for pediatric/adolescent weight loss surgery. Obesity (2009) 17, doi: /oby Yermilov I, McGory ML, Shekelle PW, Ko CY, Maggard MA. Appropriateness criteria for bariatric surgery: beyond the NIH Guidelines. Obesity (2009) 17, doi: /oby Metabolic and Accreditation and Quality Improvement Program (MBSAQIP). Standards Manual V2.0. Resources for Optimal Care of the Metabolic and Patient October Retrieved from 8. Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient 2013 Updated: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic 7. Surgery for Obesity and Related Diseases 9(2013) Retrieved from 9. Fitch A, Everling L, Fox C, et al. Institute for Clinical Systems Improvement. Prevention and Management of Obesity for Adults. Updated May Fitch A, Fox C, Bauerly K, et al. Institute for Clinical Systems Improvement. Prevention and Management of Obesity for Children and s. Published July Biro FM, Chan YM. Normal puberty. In: UpToDate, Hoppin AG (Ed), UpToDate, Waltham, MA. (Accessed on September 19, 2017.) DOCUMENT HISTORY: Created Date: 10/91 Reviewed Date: 11/10/09, 10/26/10, 10/01/12, 09/27/13, 09/26/14, 09/14/15, 09/14/16, 09/14/17 Revised Date: 05/24/05, 05/23/06, 09/25/07, 01/21/09, 09/28/09, 03/19/10, 08/17/10, 06/21/11, 09/29/11, 04/04/12, 08/22/12, 10/01/12, 07/11/13, 09/26/14, 09/26/17

9 Reference #: MC/H003 Page 9 of 13 Attachment A Designated Participating Programs IA, MN, ND, SD, WI State City Hospital Accreditation Belmond Iowa Specialty Hospital Cedar Falls Sartori Memorial Hospital Clive Mercy Medical Center Davenport Genesis Health System d/b/a Genesis Medical Center Iowa Des Moines Iowa Methodist Medical Center Grinnell Grinnell Regional Medical Center with Iowa City Mercy Iowa City Hospital Low Acuity Center University of Iowa Hospitals and Clinics Mason City Mercy Medical Center North Iowa Crosby Cuyuna Regional Medical Center Duluth St. Mary s Medical Center St. Luke s Hospital of Duluth Low Acuity Center Edina Fairview Southdale Hospital Mankato Mayo Clinic Health Systems Mankato Low Acuity Center Abbott Northwestern Hospital with Minneapolis Hennepin County Medical Center with University of Minnesota Medical Center, with Minnesota Fairview Park Rapids St. Joseph s Area Health Services Robbinsdale North Memorial Medical Center Low Acuity Center Rochester Mayo Clinic Hospital Rochester with St. Cloud St. Cloud Hospital St. Louis Park Park Nicollet Methodist Hospital with St. Joseph s Hospital St. Paul United Hospital Waconia Ridgeview Medical Center

10 Reference #: MC/H003 Page 10 of 13 North Dakota South Dakota Wisconsin Bismarck Fargo Grand Forks Sanford Bismarck St. Alexius Medical Center Sanford Medical Center Fargo Altru Health System with Low Acuity Center Avera McKennan Hospital and University with Health Center Sioux Falls with Sanford USD Medical Center Brookfield Wheaton Franciscan Healthcare-Elmbrook Memorial Green Bay Aurora BayCare Medical Center LaCrosse Gundersen Lutheran Medical Center Madison UW Health at the American Center UW Health University Hospital Marshfield Ministry St. Joseph s Hospital Aurora Health Care Metro Inc Aurora Sinai Med Center Milwaukee Columbia St. Mary s Hospital Froedtert Memorial Lutheran Hospital with Neenah ThedaCare Regional Medical Center-Neenah Wausau Aspirus Wausau Hospital Accessed Date: 09/19/17 The accuracy of designated participating bariatric surgery programs listed above applies only to the Accessed Date. For the most current list of designated participating bariatric surgery programs, including programs outside the five states mentioned in Attachment A above, please visit:

11 Reference #: MC/H003 Page 11 of 13 Attachment B Body Mass Index Conversion Table

12 Reference #: MC/H003 Page 12 of 13 Attachment C Sexual maturity rating (Tanner stages) of secondary sexual characteristics Boys - Development of external genitalia Stage 1: Prepubertal Stage 2: Enlargement of scrotum and testes; scrotal skin reddens and changes in texture Stage 3: Enlargement of penis (length at first); further growth of testes Stage 4: Increased size of penis with growth in breadth and development of glans; testes and scrotum larger, scrotal skin darker Stage 5: Adult genitalia Girls - Breast development Stage 1: Prepubertal Stage 2: Breast bud stage with elevation of breast and papilla; enlargement of areola Stage 3: Further enlargement of breast and areola; no separation of their contour Stage 4: Areola and papilla form a secondary mound above level of breast Stage 5: Mature stage: projection of papilla only, related to recession of areola Boys and girls - Pubic hair Stage 1: Prepubertal (the pubic area may have vellus hair, similar to that of forearms) Stage 2: Sparse growth of long, slightly pigmented hair, straight or curled, at base of penis or along labia Stage 3: Darker, coarser and more curled hair, spreading sparsely over junction of pubes Stage 4: Hair adult in type, but covering smaller area than in adult; no spread to medial surface of thighs Stage 5: Adult in type and quantity, with horizontal upper border Retrieved from: Biro FM, Chan YM. Normal puberty. In: UpToDate, Hoppin AG (Ed), UpToDate, Waltham, MA. (Accessed on September 19, November 4, 2015.)

13 Attachment D Overview of Designation Levels and Award Definitions Page 13 of 13 Designation Level Definition Domestic/ International Facility Volume Surgeon Volume Required Standards Patient Selection Data Registry On-site visit Required? Data Collection Center Center elects to participate in the MBSAQIP Data Registry only and is not recognized as an MBSAQIPaccredited Center Domestic and International Centers are invited to participate provided they employ a dedicated Metabolic and Bariatric Surgical Clinical Reviewer who can meet all requirements n/a n/a n/a n/a 100% of metabolic and bariatric procedures performed at the center must be entered No Comprehensive Center Center is recognized for offering all requisite resources to perform complex primary and revisional bariatric and non procedures on a high volume of patients at all acuity levels. These centers are designated to care for patients 18 years of age and older at all levels of obesity and comorbid condition. U.S and Canada only A minimum of 50 cases annually At minimum, one surgeon must have 100 lifetime cases and 75 cases over the previous 3 years (25 per year) 1.1, 2-7 All patients 18 years of age and older 100% of metabolic and bariatric procedures performed at the center must be entered Yes, every 3 years* Comprehensive Center with Qualifications Center is recognized for offering all requisite resources to perform complex primary and revisional bariatric and non procedures on a high volume of patients at all acuity levels. These centers are designated to care for patients at all levels of obesity, age, and comorbid conditions. U.S and Canada only A minimum of 50 cases annually At minimum, one surgeon must have 100 lifetime cases and 75 cases over the previous 3 years (25 per year) 1.1, 2-7, 9.2, and 9.3 All patients 100% of metabolic and bariatric procedures performed at the center must be entered Yes, every 3 years* Low Acuity Center Center is recognized for offering all requisite resources to perform primary and revisional bariatric and band procedures on a minimum volume of low acuity patients (see definition in Standard 1.2). These centers are restricted from performing elective revisional intraabdominal procedures with the exception of emergent cases. U.S and Canada only A minimum of 25 cases annually At minimum, one surgeon must have 100 lifetime cases and 75 cases over the previous 3 years (25 per year) 1.1, 1.2, 2-7 Restricted to Low Acuity patients (see Standard 1.2 for definition) 18 years of age and older 100% of metabolic and bariatric procedures performed at the center must be entered Yes, every 3 years* Ambulatory Surgery Center Center is recognized for offering all requisite resources, either onsite or through transfer to an MBSAQIP-Accredited Inpatient Center, to perform primary and revisional bariatric procedures on a minimum volume of low acuity patients (see definition in Standard 1.2). These centers are restricted from performing elective revisional intraabdominal procedures with the exception of emergent cases. U.S and Canada only A minimum of 25 cases annually At minimum, one surgeon must have 100 lifetime cases and 75 cases over the previous 3 years (25 per year) 1.1, 1.2, 2-8 Restricted to Low Acuity patients (see Standard 1.2 for definition) 18 years of age and older 100% of metabolic and bariatric procedures performed at the center must be entered Yes, every 3 years Center Children s hospital that is recognized for offering all requisite resources to perform complex primary and revisional bariatric procedures on patients at all acuity levels. These centers are designated to care for patients at all levels of obesity, age, and comorbid conditions. U.S and Canada only No facility volume requirement for designation; however, restrictions do apply for centers performing < 25 MBSAQIP approved procedures annually (see Standard 9.1) At minimum, one surgeon must have 100 lifetime cases and 75 cases over the previous 3 years (25 per year) 1.1, 2-7, and 9 All patients 100% of metabolic and bariatric procedures performed at the center must be entered *See pathways on pages 10 and 11 of the MBSAQIP Standards Manual for exceptions to site visit requirements when converting status from another designation level prior to your three-year renewal. Yes, every 3 years Retrieved from Metabolic and Accreditation and Quality Improvement Program (MBSAQIP). Standards Manual V2.0. Resources for Optimal Care of the Metabolic and Patient 2016.

14 PreferredOne Community Health Plan Nondiscrimination Notice PreferredOne Community Health Plan ( PCHP ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PCHP: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PCHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Community Health Plan PO Box Minneapolis, MN Phone: (TTY: ) Fax: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at Language Assistance Services NDR PCHP LV (10/16)

15 PreferredOne Insurance Company Nondiscrimination Notice PreferredOne Insurance Company ( PIC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PIC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PIC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Insurance Company PO Box Minneapolis, MN Phone: (TTY: ) Fax: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at Language Assistance Services NDR PIC LV (10/16)