Bariatric Surgery

Policy ID: S-331-001

Section: Surgery

Effective Date: January 06, 2025

Revised Date: November 21, 2024

Last Reviewed: November 19, 2024

Applies To: Commercial and Medicaid Expansion

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

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

Adolescent Criteria

Bariatric surgery may be considered medically necessary for individuals under the age of 18 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)

The individual has attained or nearly attained physiologic/skeletal maturity at approximately, age 13 in girls and 15 for boys. (The individual has attained final or near-final adult height (e.g., 95 percent or greater) of adult stature)
The individual is morbidly obese or severely obese as defined by ONE or more of the following
- BMI greater than (>) 50 kg/m2 or greater than (>) 140% of the 95th percentile (class III obesity)
- BMI greater than (>) 40 kg/m2 or greater than (>) 120% of the 95th percentile (class II obesity) with ONE or more of the following
  - Hypertension
  - Insulin resistance
  - Glucose intolerance
  - Dyslipidemia
  - Clinically significant OSA
  - Substantially impaired quality of life or activities of daily living
- BMI between 35-40 kg/m2 with ONE or more of the following
  - Type II diabetes
  - Moderate to severe OSA (apnea-hypopnea index greater than (>) 15)
  - Pseudotumor cerebri
  - 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 had 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
The individual shows decisional capacity and maturity in the psychological evaluation and provide informed assent for surgical management
The individual is capable and willing to adhere to nutritional guidelines postoperatively
The individual has a supportive and committed family environment
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

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
Gastrogastric fistula associated with ulcers, gastroesophageal reflux disease (GERD) and weight gain
Band erosion
Disruption/anastomotic leakage of a suture/staple line
Tubing leak or port dislocation
Small bowel obstruction
Band intolerance with obstructive symptoms (e.g. vomiting, esophageal spasm)
Band slippage and/or prolapse that cannot be corrected with manipulation or adjustment
Stricture/stenosis with dysphagia, solid food intolerance and/or severe reflux
Stomal stenosis
Refractory marginal ulcers
Non-absorption resulting in hypocalcemia or malnutrition
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 ONE or more 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
Replacement of an adjustable band if there are complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments
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.

Procedure Codes

43644

43771

43772

43773

43774

43775

43845

43846

43848

43886

43887

43888

43860

43865

The following bariatric procedures are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Endoscopic procedures including but not limited to
- StomaphyX™ device or restorative obesity surgery (ROSE) procedure
- Aspiration therapy devices
- Endoscopic gastroplasty
- Gastrointestinal Liners (e.g., the EndoBarrier)
- Gastric balloons
- Transoral outlet reduction (TORe)
Biliopancreatic bypass (the Scopinaro procedure) or laparoscopic
Intestinal bypass
Laparoscopic gastric plication
Vagal nerve blocking (VBLOC) therapy (neuromodulation non-metabolic), also known as the Maestro implant or Maestro rechargeable system
Mini-gastric bypass
Vertical banded gastroplasty
Single anastomosis duodenal-ileal bypass with Sleeve Gastrectomy (SIPS OR SADI)

Procedure Codes

0813T

43290

43291

43659

43842

43999

44238

44799

Outpatient HCPCS (C Codes)

C9784

C9785

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes43644; 43645; 43770; 43775; 43843; 43846; 43847; and S2083

E66.01

E66.812

E66.813

Z68.35

Z68.36

Z68.37

Z68.38

Z68.39

Z68.41

Z68.42

Z68.43

Z68.44

Z68.45

Z68.55

Z68.56

Covered Diagnosis Codes for Procedure Code 43845

E66.01

Z68.43

Z68.44

Z68.45

Non-Covered Diagnosis Codes

E66.1

E66.3

E66.811

E66.89

E66.9

E66.09

Professional Statements and Societal Positions Guidelines

American Academy of Pediatrics, 2023

The American Academy of Pediatrics published its 'Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity.' The guideline recommends that metabolic and bariatric surgery (MBS) be considered for obesity when medical or lifestyle treatments are not sufficient for youth with class 3 obesity (BMI greater than or equal to (≥) 140% of the 95th percentile or BMI greater than or equal to (≥) 40 kg/m2) or class 2 obesity (BMI greater than or equal to (≥) 120 to 140% of the 95th percentile or BMI greater than or equal to (≥) 35 kg/m2) with a comorbidity including obstructive sleep apnea, type 2 diabetes, idiopathic intracranial hypertension, gastroesophageal reflux, or hypertension.

ND Committee Review

Internal Medical Policy Committee 11-19-2024 New Policy - Effective January 06, 2025

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-24-066

Section: Miscellaneous

Effective Date: July 01, 2018

Revised Date: November 21, 2024

Revision Effective Date: January 06, 2025

Last Reviewed: November 19, 2024

Archived Date: January 05, 2025

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 percent to 30 percent 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 percent over ideal weight or a body mass index (BMI) of at least 40 or a BMI of 35 with comorbidities.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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;

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.

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; or
- Note: 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:
- Laparoscopic adjustable banding is an eligible procedure ONLY when 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 years or under.

Selection Criteria for Adults

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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 EITHER:
  - - A weight which is at least 100 lbs. or 100% over ideal weight; or
    - A BMI of at least 40 kg/m ² ; or
    - A BMI of 35 kg/m ² with ANYONE 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
      - Coronary heart disease (with objective documentation (by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, heart failure, or prior myocardial infarction); or
      - Hyperlipidemia (above 30mg/dl above guideline-directed goal) on maximum doses of monotherapy; or
      - Diabetes mellitus type II; with glycosylated hemoglobin (HbA1C) above 8.0 percent on one (1) or more medications; or
      - Obstructive sleep apnea (OSA); (diagnosed by polysomnography showing apnea-hypopnea index of 15 events per hour or more); or
      - Obesity-hypoventilation syndrome (OHS); or
      - Pickwickian syndrome (a combination of OSA and OHS); or
      - Nonalcoholic fatty liver disease (NAFLD); or
      - Pseudotumor Cerebri; or
      - Nonalcoholic steatohepatitis (NASH); and
The individual must have 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 for weight reduction should include changes to the individual's dietary, medication, and exercise regimen; and
The individual must complete a multidisciplinary evaluation including medical, nutritional, and psychological evaluations. A psychological evaluation must be performed by a licensed mental health care professional, and the individual must 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.

Bariatric procedures not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

43644

43770

43775

43843

43845

43846

S2083

Selection Criteria for Adolescents

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

The eligible bariatric surgical procedures listed above unless otherwise specified may be considered medically necessary 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 final or near-final adult height (e.g., 95 percent or greater) of adult stature); and
The individual is morbidly obese defined as:
- BMI greater than 50 kg/m ² or greater than 140 percent of the 95th percentile (class III obesity); or
- Severely obese defined as a BMI greater than 40 kg/m ² or greater than 120 percent of the 95th percentile (class II obesity); and
- The individual has ANYONE 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;

- A BMI between 35-40 kg/m ² 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 must 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.

Bariatric procedures not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

43644

43770

43775

43843

43845

43846

Repeat or Revised Bariatric Surgical Procedures

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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.

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.

Procedure Codes

43644

43771

43772

43773

43774

43775

43845

43846

43848

43860

43865

43886

43887

43888

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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); or
Biliopancreatic bypass (the Scopinaro procedure) or laparoscopic; or
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; or
Single anastomosis duodenal-ileal bypass with Sleeve Gastrectomy (SIPS or SADI)

Procedure Codes

0813T

43290

43291

43645

43659

43842

43847

43999

44238

44799

Outpatient HCPCS (C codes)

C9784

C9785

Diagnosis Codes

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

E66.01

E66.812

E66.813

Z68.35

Z68.36

Z68.37

Z68.38

Z68.39

Z68.41

Z68.42

Z68.43

Z68.44

Z68.45

Z68.55

Z68.56

Covered Diagnosis Codes for Procedure Code: 43845

E66.01

Z68.43

Z68.44

Z68.45

Non-Covered Diagnosis Codes

E33.811

E66.1

E66.3

E66.89

E66.9

E66.09

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Revision

Removed reimbursement language; and
Added SAID, SIPS procedure to experimental/investigational list.

Internal Medical Policy Committee 11-19-2020 Revision

Changed 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

Internal Medical Policy Committee 1-20-2022 Revision with coding updates;

Added procedure codes 43659 and 44238

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 1, 2023

Removed procedure codes 0312T; 0313T; 0314T; 0315T; 0316T; 0317T; and
Added procedure codes 43290; 43291; 43860 and 43865.

Internal Medical Policy Committee 3-23-2023 Revision - Effective May 1, 2023

Updated criteria

Internal Medical Policy Committee 7-26-2023 Coding update- Effective July 1, 2023

Added procedure codes C9784, C9785

Internal Medical Policy Committee 1-16-2024 Coding update - Effective January 1, 2024

Added new procedure code 0813T

Internal Medical Policy Committee 9-17-2024 Coding update - Effective October 1, 2024

Added new diagnosis codes E66.812, E66.813, Z68.55, and Z68.56; and
Added non-covered diagnosis codes E33.811 and E66.89; and
Removed diagnosis code E66.8; and
Added application status.

Internal Medical Policy Committee 11-19-2024 Effective January 6, 2025

Archived policy

Medical Policies Quick Search

Bariatric Surgery

Description

Criteria

Procedure Codes

Procedure Codes

Procedure Codes

Outpatient HCPCS (C Codes)

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Outpatient HCPCS (C codes)

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer