Repeat or Revised Bariatric Surgical Procedures
Surgical repair to correct perioperative or late chronic complications of a bariatric procedure may be considered medically necessary when there is documentation of a surgical complication related to the perioperative or late chronic complications of a bariatric procedure. These include but are not limited to:
- Enteric fistula that does not close with bowel rest and nutritional support; or
- Gastrogastric fistula associated with ulcers, gastroesophageal reflux disease (GERD) and weight gain; or
- Band erosion; or
- Disruption/anastomotic leakage of a suture/staple line; or
- Tubing leak or port dislocation; or
- Small bowel obstruction; or
- Band intolerance with obstructive symptoms (e.g. vomiting, esophageal spasm); or
- Band slippage and/or prolapse that cannot be corrected with manipulation or adjustment; or
- Stricture/stenosis with dysphagia, solid food intolerance and/or severe reflux; or
- Stomal stenosis; or
- Refractory marginal ulcers; or
- Non-absorption resulting in hypocalcemia or malnutrition; or
- Weight loss of 20 percent or more below ideal body weight.
Repeat surgical procedures for revision or conversion to another surgical procedure may be considered medically necessary when the initial bariatric surgery was medically necessary (and the individual continues to meet all the medical necessity criteria for bariatric surgery); and when ANY ONE of the following criteria is met:
- A conversion to a sleeve gastrectomy, RYGB or biliopancreatic bypass with duodenal switch (BPD/DS) for individuals who have not had adequate weight loss success (defined as less than 50 percent of excess body weight) two (2) years following the primary bariatric surgery procedure and the individual has been compliant with a prescribed nutrition and exercise program following the procedure;
- A revision of a primary bariatric surgery procedure that has failed due to dilatation of the gastric pouch, dilated gastrojejunal stoma, or dilation of the gastrojejunostomy (GJ) anastomosis if the primary procedure was successful in inducing weight loss prior to the dilation of the pouch or GJ anastomosis, and the individual has been compliant with a prescribed nutrition and exercise program following the procedure; or
- Replacement of an adjustable band if there are complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments; or
- A conversion from an adjustable band to a sleeve gastrectomy, RYGB or BPD/DS for individuals who have been compliant with a prescribed nutrition and exercise program following the band procedure and have experienced complications that cannot be corrected with band manipulation, adjustments or replacement.
Individual postoperative noncompliance negates the efficacy of revision or conversion surgery.
Conversion or revision surgery is considered not medically necessary when due to inadequate weight loss related to non-compliance with post-operative nutrition and exercise recommendations.
Repeat procedures for repair, revision, or conversion to another surgical procedure following a gastric bypass or gastric restrictive procedure not meeting the criteria as indicated in this policy are considered not medically necessary.