Bariatric Surgery

Policy ID: G-24-059

Section: Miscellaneous

Effective Date: July 01, 2018

Revised Date: December 03, 2021

Revision Effective Date: January 03, 2022

Last Reviewed: November 23, 2021

Applies To: Commercial and Medicaid Expansion

Description

Obesity is an increase in body weight beyond the limitation of skeletal and physical requirements, as a result of excessive accumulation of fat in the body. In general, 20% to 30% above "ideal" bodyweight, according to standard life insurance tables, constitutes obesity. Morbid obesity is further defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% 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 malabsorpive 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;

The following bariatric procedures may be considered medically necessary for the surgical treatment of morbid obesity when ALL of the selection criteria are met. Bariatric surgery should be performed in appropriately selected individuals by surgeons who are adequately trained and experienced in the specific techniques used and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up post-surgery.

Laparoscopic adjustable gastric banding using an FDA-approved adjustable gastric band; or
Biliopancreatic bypass with duodenal switch (or open procedure) for individuals with a BMI of 50 kg/m2 or greater; or
Roux-en-Y gastric bypass (RYGB) (laparoscopic or open procedure); or
Sleeve Gastrectomy (laparoscopic or open procedure)
- 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).

Selection Criteria for Adults

The individual is morbidly obese and is at least 18 years of age. Morbid obesity is defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% over ideal weight or a BMI of at least 40 kg/m² or a BMI of 35 kg/m² with ANY ONE or more of the following comorbidities:
- 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); or
- 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); or
- Hyperlipidemia; or
- Diabetes mellitus type II; or
- Obstructive sleep apnea (OSA); or
- Obesity-hypoventilation syndrome (OHS); or
- Pickwickian syndrome (a combination of OSA and OHS); or
- Nonalcoholic fatty liver disease (NAFLD); or
- Nonalcoholic steatohepatitis (NASH); and

The individual should have documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure. As a result, some centers require active participation in a formal weight reduction program that includes frequent documentation of weight, dietary regimen, and exercise. However, there is a lack of evidence on the optimal timing, intensity and duration of nonsurgical attempts at weight loss, and whether a medical weight loss program immediately preceding surgery improves outcomes; and

The individual must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. 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; and
Individual selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The individual's understanding of the procedure and 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) are necessary to the success of the procedure.

If the individual does not meet ALL of the selection criteria for bariatric surgery, the procedure will be denied as not medically necessary.

Procedure Codes

43644

43770

43775

43843

43845

43846

S2083

Selection Criteria for Adolescents

The eligible bariatric surgical procedures listed above unless otherwise specified are covered for individuals under the age of 18 years when they meet ALL of the following criteria:

Attainment or near-attainment of physiologic/skeletal maturity at approximately, age 13 in girls and 15 for boys. (The individual has attained Tanner 4 pubertal development and final or near-final adult height (e.g., 95 % or greater) of adult stature); and
The individual is morbidly obese defined as a BMI greater than 50 kg/m2 or severely obese defined as a BMI greater than 40 kg/m2 with ANY ONE or more obesity-related comorbidities:
- Hypertension; or
- Insulin resistance; or
- Glucose intolerance; or
- Dyslipidemia; or
- Clinically significant OSA; or
- Substantially impaired quality of life or activities of daily living; or
A BMI between 35-40 kg/m2 in addition to ONE or more serious obesity related comorbidities;
- Type II diabetes; or
- Moderate to severe OSA (apnea-hypopnea index greater than 15); or
- Pseudotumor cerebri; or
- NASH; and
Individuals should have documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure. As a result, some centers require active participation in a formal weight reduction program that includes frequent documentation of weight, dietary regimen, and exercise. However, there is a lack of evidence on the optimal timing, intensity and duration of nonsurgical attempts at weight loss, and whether a medical weight loss program immediately preceding surgery improves outcomes; and
The individual must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed; and
The individual must be able to show decisional capacity and maturity in the psychological evaluation and provide informed assent for surgical management; and
The individual must be capable and willing to adhere to nutritional guidelines postoperatively; and
The individual must have a supportive and committed family environment; and
Selection criteria is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The individual's understanding of the procedure and 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) are necessary to the success of the procedure.

If the adolescent does not meet ALL of the adolescent selection criteria for bariatric surgery, the procedure will be denied as not medically necessary.

Procedure Codes

43644

43770

43775

43843

43845

43846

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% 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% 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 are considered not medically necessary when the criteria listed above are not met.

Procedure Codes

43644

43771

43772

43773

43774

43775

43845

43846

43848

43886

43887

43888

The following bariatric procedures are considered experimental/investigational, and therefore, non-covered. There is insufficient evidence in the peer-reviewed published medical literature regarding effectiveness and safety of these procedures.

Endoscopic procedures including but not limited to;
- StomaphyX™ device or restorative obesity surgery (ROSE) procedure; or
- Aspiration therapy devices; or
- Endoscopic gastroplasty; or
- Gastrointestinal Liners (e.g., the EndoBarrier); or
- Gastric balloons; or
- Transoral outlet reduction (TORe)

Biliopancreatic bypass (the Scopinaro procedure) or laparoscopic; or
The long-limb gastric bypass; or
Intestinal bypass; or
Laparoscopic gastric plication; or
Vagal nerve blocking (VBLOC) therapy (neuromodulation non-metabolic), also known as the Maestro implant or Maestro rechargeable system; or
Mini-gastric bypass; or
Vertical banded gastroplasty
Single anastomosis duodenal-ileal bypass with Sleeve Gastrectomy (SIPS or SADI)

Procedure Codes

43645

43842

43847

43999

0312T

0313T

0314T

0315T

0316T

0317T

44799

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 43644, 43770, 43775, 43843, 43846, S2083

E66.01

Z68.35

Z68.36

Z68.37

Z68.38

Z68.39

Z68.41

Z68.42

Z68.43

Z68.44

Z68.45

Covered Diagnosis Codes for Procedure Codes: 43845

E66.01

Z68.43

Z68.44

Z68.45

Non-Covered Diagnosis Codes

E66.1

E66.3

E66.8

E66.9

E66.09

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Removed reimbursement language; added SADI, SIPS procedure to experimental/investigational list.

Internal Medical Policy Committee 11-19-2020 Change in Title from Obesity to Bariatric Surgery

Internal Medical Policy Committee 11-23-2021 Revision added the length of time required for psychological evaluation to have documented prior to surgery

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: G-24-059

Section: Miscellaneous

Effective Date: July 01, 2018

Revised Date: November 30, 2020

Revision Effective Date: January 04, 2021

Last Reviewed: November 19, 2020

Archived Date:January 02, 2022

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Covered gastric restrictive or malabsorpive 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/quality-programs/mbsaqip; or
A member of the Blue Distinction Centers for Bariatric Surgery;

Laparoscopic adjustable gastric banding using an FDA-approved adjustable gastric band; or
Biliopancreatic bypass with duodenal switch (or open procedure) for individuals with a BMI of 50 kg/m2 or greater; or
Roux-en-Y gastric bypass (RYGB) (laparoscopic or open procedure); or
Sleeve Gastrectomy (laparoscopic or open procedure)
- 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).

Selection Criteria for Adults

The individual is morbidly obese and is at least 18 years of age. Morbid obesity is defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% over ideal weight or a BMI of at least 40 kg/m² or a BMI of 35 kg/m² with ANY ONE or more of the following comorbidities:
- 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); or
- 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); or
- Hyperlipidemia; or
- Diabetes mellitus type II; or
- Obstructive sleep apnea (OSA); or
- Obesity-hypoventilation syndrome (OHS); or
- Pickwickian syndrome (a combination of OSA and OHS); or
- Nonalcoholic fatty liver disease (NAFLD); or
- Nonalcoholic steatohepatitis (NASH); and

The individual should have documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure. As a result, some centers require active participation in a formal weight reduction program that includes frequent documentation of weight, dietary regimen, and exercise. However, there is a lack of evidence on the optimal timing, intensity and duration of nonsurgical attempts at weight loss, and whether a medical weight loss program immediately preceding surgery improves outcomes; and

The individual must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed; and
Individual selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The individual's understanding of the procedure and 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) are necessary to the success of the procedure.

If the individual does not meet ALL of the selection criteria for bariatric surgery, the procedure will be denied as not medically necessary.

Procedure Codes

43644

43770

43775

43843

43845

43846

S2083

Selection Criteria for Adolescents

The eligible bariatric surgical procedures listed above unless otherwise specified are covered for individuals under the age of 18 years when they meet ALL of the following criteria:

Attainment or near-attainment of physiologic/skeletal maturity at approximately, age 13 in girls and 15 for boys. (The individual has attained Tanner 4 pubertal development and final or near-final adult height (e.g., 95 % or greater) of adult stature); and
The individual is morbidly obese defined as a BMI greater than 50 kg/m2 or severely obese defined as a BMI greater than 40 kg/m2 with ANY ONE or more obesity-related comorbidities:
- Hypertension; or
- Insulin resistance; or
- Glucose intolerance; or
- Dyslipidemia; or
- Clinically significant OSA; or
- Substantially impaired quality of life or activities of daily living; or
A BMI between 35-40 kg/m2 in addition to ONE or more serious obesity related comorbidities;
- Type II diabetes; or
- Moderate to severe OSA (apnea-hypopnea index greater than 15); or
- Pseudotumor cerebri; or
- NASH; and
Individuals should have documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure. As a result, some centers require active participation in a formal weight reduction program that includes frequent documentation of weight, dietary regimen, and exercise. However, there is a lack of evidence on the optimal timing, intensity and duration of nonsurgical attempts at weight loss, and whether a medical weight loss program immediately preceding surgery improves outcomes; and
The individual must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed; and
The individual must be able to show decisional capacity and maturity in the psychological evaluation and provide informed assent for surgical management; and
The individual must be capable and willing to adhere to nutritional guidelines postoperatively; and
The individual must have a supportive and committed family environment; and
Selection criteria is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The individual's understanding of the procedure and 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) are necessary to the success of the procedure.

If the adolescent does not meet ALL of the adolescent selection criteria for bariatric surgery, the procedure will be denied as not medically necessary.

Procedure Codes

43644

43770

43775

43843

43845

43846

Repeat or Revised Bariatric Surgical Procedures

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
Tubingleak 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% or more below ideal body weight.

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% 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.

Procedure Codes

43644

43771

43772

43773

43774

43775

43845

43846

43848

43886

43887

43888

Endoscopic procedures including but not limited to;
- StomaphyX™ device or restorative obesity surgery (ROSE) procedure; or
- Aspiration therapy devices; or
- Endoscopic gastroplasty; or
- Gastrointestinal Liners (e.g., the EndoBarrier); or
- Gastric balloons; or
- Transoral outlet reduction (TORe)

Biliopancreatic bypass (the Scopinaro procedure) or laparoscopic; or
The long-limb gastric bypass; or
Intestinal bypass; or
Laparoscopic gastric plication; or
Vagal nerve blocking (VBLOC) therapy (neuromodulation non-metabolic), also known as the Maestro implant or Maestro rechargeable system; or
Mini-gastric bypass; or
Vertical banded gastroplasty
Single anastomosis duodenal-ileal bypass with Sleeve Gastrectomy (SIPS or SADI)

Procedure Codes

43645

43842

43847

43999

0312T

0313T

0314T

0315T

0316T

0317T

44799

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 43644, 43770, 43775, 43843, 43846, S2083

E66.01

Z68.35

Z68.36

Z68.37

Z68.38

Z68.39

Z68.41

Z68.42

Z68.43

Z68.44

Z68.45

Covered Diagnosis Codes for Procedure Codes: 43845

E66.01

Z68.43

Z68.44

Z68.45

Non-Covered Diagnosis Codes

E66.1

E66.3

E66.8

E66.9

E66.09

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Removed reimbursement language; added SADI, SIPS procedure to experimental/investigational list.

Internal Medical Policy Committee 11-19-2020 Change in Title from Obesity to Bariatric Surgery

Links

References (PDF)

Disclaimer

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