Description
Bariatric surgery is a treatment for obesity in individuals who fail to lose weight with conservative measures. Obesity is an increase in body weight beyond the limitation of skeletal and physical requirements because of excessive accumulation of fat in the body.
According to standard life insurance tables, obesity is constituted as 20 to 30 percent above 'ideal' bodyweight. Morbid obesity is further characterized by a weight which is at least 100 lbs. or 100 percent over ideal weight or a body mass index (BMI) of at least 40 or a BMI of 35 with comorbidities.
Criteria
Covered gastric restrictive or malabsorptive procedures must be performed in an approved facility with one of the following accreditations
- accredited by the metabolic and Bariatric Surgery Accreditation and Quality Improvement Program,
https://www.facs.org/search/bariatric-surgery-centers
or
A member of the Blue Distinction Centers for Bariatric Surgery.
Adult Criteria
Bariatric surgery may be considered medically necessary
for individuals aged 18or over
when
ALL
of the following criteria are met
-
The procedure is
ONE or more
of the following
- Biliopancreatic bypass with duodenal switch (or open procedure for individuals with a BMI of 50 kg/m2 or greater)
- Roux-en-Y gastric bypass (RYGB) (laparoscopic or open procedure)
- Sleeve Gastrectomy (laparoscopic or open procedure)
NOTE:
Sleeve gastrectomy is an eligible procedure as a first stage of a two-stage procedure or as a sole definitive procedure. For high BMI individuals in whom the duodenal switch may be difficult, it is reasonable to do a sleeve gastrectomy as the first stage of an intended two-stage duodenal switch. This does permit subsequent assessment of both the efficacy of the sleeve (to see whether the second stage is really needed), assessment of the compliance of the individual (to see whether the more complicated procedure is justified) or to examine the metabolic and nutritional effects of the sleeve (to see whether potential further metabolic derangements of the duodenal switch would make it unadvisable)
-
Laparoscopic adjustable gastric banding using an FDA approved adjustable gastric band when
ALL
of the following criteria are met
- A contraindication to biliopancreatic bypass with duodenal switch, Rou-en-Y gastric bypass, and sleeve gastrectomy is documented in the medical record
- Laparoscopic adjustable gastric banding is contraindicated for individuals aged 17 year or under.
-
The individual is morbidly obese as defined by
ONE or more
of the following
- A weight which is at least 100 lbs. or 100% over ideal weight
- A BMI of at least 40 kg/m2
-
A BMI of 35 kg/m2 with
ONE or more
of the following
- Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of three (3) anti-hypertensive agents of different classes)
- Cardiovascular heart disease (with objective documentation by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure or prior myocardial infarction)
- Coronary heart disease (with objective documentation (by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure, or prior myocardial infarction)
- Hyperlipidemia (above 30mg/dl above guideline-directed goal) on maximum doses of monotherapy
- Diabetes mellitus type II with glycosylated hemoglobin (HbA1C) above 8.0% on one or more medications
- Obstructive sleep apnea (OSA) (diagnosed by polysomnography showing apnea-hypopnea index of 15 events/hour or more)
- Obesity-hypoventilation syndrome (OHS)
- Pickwickian syndrome (a combination of OSA and OHS)
- Nonalcoholic fatty liver disease (NAFLD)
- Pseudotumor Cerebri
- Nonalcoholic steatohepatitis (NASH)
- The individual has documented failure to respond to conservative measures for weight reduction for a period of at least six (6) consecutive months prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure (Conservative measures include changes to the individual's dietary and exercise regimen)
The individual has completed a multidisciplinary evaluation including medical, nutritional, and psychological evaluations. The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed. Psychological evaluation documentation must be within the last year
- The individual understands the procedure and has the ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program)
Bariatric surgery not meeting the criteria as indicated in this policy is considered not medically necessary.
Procedure Codes
43644 | 43645 | 43770 | 43775 | 43843 | 43845 | 43846 |
43847 | S2083 |
