policy-tree/oscar.json at main · dev-pd/policy-tree · GitHub

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{
    "title": "Medical Necessity Criteria for Bariatric Surgery",
    "insurance_name": "Oscar Health",
    "rules": {
        "rule_id": "1",
        "rule_text": "Procedures are considered medically necessary when ALL of the following criteria are met",
        "operator": "AND",
        "rules": [
            {
                "rule_id": "1.1",
                "rule_text": "Informed consent with appropriate explanation of risks, benefits, and alternatives"
            },
            {
                "rule_id": "1.2",
                "rule_text": "Adult aged 18 years or older with documentation of",
                "operator": "OR",
                "rules": [
                    {
                        "rule_id": "1.2.1",
                        "rule_text": "Body mass index (BMI) ≥40"
                    },
                    {
                        "rule_id": "1.2.2",
                        "rule_text": "BMI greater ≥35 with ONE of the following severe obesity-related comorbidities",
                        "operator": "OR",
                        "rules": [
                            {
                                "rule_id": "1.2.2.1",
                                "rule_text": "Clinically significant cardio-pulmonary disease (e.g. severe obstructive sleep apnea (OSA), obesity-hypoventilation syndrome (OHS))"
                            },
                            {
                                "rule_id": "1.2.2.2",
                                "rule_text": "Coronary artery disease, objectively documented via stress test, echocardiography, angiography, prior myocardial infarction, or similar"
                            },
                            {
                                "rule_id": "1.2.2.3",
                                "rule_text": "Objectively documented cardiomyopathy"
                            },
                            {
                                "rule_id": "1.2.2.4",
                                "rule_text": "Medically refractory hypertension (defined as > 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 antihypertensive agents)"
                            },
                            {
                                "rule_id": "1.2.2.5",
                                "rule_text": "Type 2 diabetes mellitus"
                            },
                            {
                                "rule_id": "1.2.2.6",
                                "rule_text": "Nonalcoholic fatty liver disease or nonalcoholic steatohepatitis"
                            },
                            {
                                "rule_id": "1.2.2.7",
                                "rule_text": "Osteoarthritis of the knee or hip or improving outcomes of knees or hip replacement"
                            },
                            {
                                "rule_id": "1.2.2.8",
                                "rule_text": "Urinary stress incontinence"
                            }
                        ]
                    },
                    {
                        "rule_id": "1.2.3",
                        "rule_text": "BMI ≥30-34.9, see section below"
                    }
                ]
            },
            {
                "rule_id": "1.3",
                "rule_text": "Failure to achieve and maintain successful long-term weight loss via non-surgical therapy"
            },
            {
                "rule_id": "1.4",
                "rule_text": "The proposed bariatric surgery includes a comprehensive pre- and post-operative plan",
                "operator": "AND",
                "rules": [
                    {
                        "rule_id": "1.4.1",
                        "rule_text": "Preoperative evaluation to rule out and treat any other reversible causes of weight gain/obesity",
                        "operator": "AND",
                        "rules": [
                            {
                                "rule_id": "1.4.1.1",
                                "rule_text": "Basic laboratory testing (blood glucose, lipid panel, CBC, metabolic panel, blood typing, coagulation studies)"
                            },
                            {
                                "rule_id": "1.4.1.2",
                                "rule_text": "Nutrient deficiency screening and formal nutrition evaluation"
                            },
                            {
                                "rule_id": "1.4.1.3",
                                "rule_text": "Cardiopulmonary risk evaluation"
                            },
                            {
                                "rule_id": "1.4.1.4",
                                "rule_text": "GI evaluation"
                            },
                            {
                                "rule_id": "1.4.1.5",
                                "rule_text": "Endocrine evaluation"
                            },
                            {
                                "rule_id": "1.4.1.6",
                                "rule_text": "Age appropriate cancer screening verified complete and up to date"
                            },
                            {
                                "rule_id": "1.4.1.7",
                                "rule_text": "Smoking cessation counseling, if applicable"
                            }
                        ]
                    }
                ]
            },
            {
                "rule_id": "1.5",
                "rule_text": "Psycho-social behavioral evaluation",
                "operator": "AND",
                "rules": [
                    {
                        "rule_id": "1.5.1",
                        "rule_text": "No current substance abuse has been identified"
                    },
                    {
                        "rule_id": "1.5.2",
                        "rule_text": "Members who have any of the following conditions MUST have formal, documented preoperative psychological clearance",
                        "operator": "OR",
                        "rules": [
                            {
                                "rule_id": "1.5.2.1",
                                "rule_text": "A history of schizophrenia, borderline personality disorder, suicidal ideation, severe depression"
                            },
                            {
                                "rule_id": "1.5.2.2",
                                "rule_text": "Who are currently under the care of a psychologist/psychiatrist"
                            },
                            {
                                "rule_id": "1.5.2.3",
                                "rule_text": "Who are on psychotropic medications"
                            }
                        ]
                    }
                ]
            }
        ]
    }
}