ALL of the following

• Member is an adult (age ≥ 18 years) or an adolescent who has completed skeletal growth (generally ≥13 years for girls, ≥15 years for boys).
• Persistent severe obesity documented in contemporaneous clinical records, defined as either: BMI > 40 kg/m2 (or > 37.5 kg/m2 for persons of Asian ancestry), OR BMI > 35 kg/m2 (or > 32.5 kg/m2 for persons of Asian ancestry) with at least one of the following severe comorbidities: clinically significant obstructive sleep apnea, coronary heart disease with objective documentation, medically refractory hypertension (BP >140/90 mmHg despite ≥3 antihypertensive agents of different classes), type 2 diabetes mellitus, or nonalcoholic steatohepatitis (NASH) confirmed by biopsy or advanced fibrosis by noninvasive testing.
• Member has attempted weight loss previously without successful long-term weight reduction and has participated in an intensive multicomponent behavioral intervention documented in the medical record (program with ≥12 sessions on separate dates within 2 years prior to surgery; may be group or individual, in-person or remote, and includes nutrition, physical activity, and behavioral modification components).
• Screening for obstructive sleep apnea using a validated tool (e.g., ESS, STOP, STOP‑Bang, Berlin, Wisconsin Sleep Questionnaire, MVAP). Documentation that screening was performed must be in the medical record (screening not required if member already has a diagnosis of OSA).
• For members with active substance abuse disorder, history of eating disorder (in addition to obesity), or severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, uncontrolled severe depression) or who are currently under care of a psychologist/psychiatrist, preoperative psychological clearance by a licensed psychologist or psychiatrist is required to confirm ability to provide informed consent and comply with pre/post-operative regimen.

ALL of the following

• Member meets the general selection criteria for obesity surgery (see Initial bariatric surgery criteria).
• Member is at increased risk of adverse consequences from RYGB due to the presence of any of the following: demonstrated extensive intestinal adhesions from prior major abdominal surgery or trauma, hepatic cirrhosis with elevated liver function tests, inflammatory bowel disease (Crohn's disease or ulcerative colitis), poorly controlled systemic disease (ASA Class IV), or radiation enteritis.

ANY of the following

• Removal of a gastric band when recommended by the treating physician (e.g., band erosion, infection, irreparable malfunction).
• Surgery to correct complications from bariatric surgery such as obstruction, stricture, erosion, or band slippage when clinically indicated and documented.
• Surgery for symptomatic 'candy cane' (Roux) syndrome when diagnosis is confirmed by endoscopy or upper GI contrast studies and member has compatible symptoms (abdominal pain, nausea, emesis).
• Replacement of an adjustable band when there are complications (e.g., port leakage, irreparable slippage) that cannot be corrected with band manipulation or adjustments.
• Conversion of sleeve gastrectomy to Roux‑en‑Y gastric bypass for treatment of symptomatic gastroesophageal reflux disease (GERD) only when: (1) reflux is documented by abnormal 24‑hour pH monitoring or endoscopically proven esophagitis performed after sleeve gastrectomy; and (2) symptoms persist despite optimal medical therapy including behavioral modification and at least one month of maximum PPI therapy.
• Repeat bariatric surgery (conversion or revision) for members whose initial bariatric surgery was medically necessary and who meet specified criteria, including inadequate success (sustained loss of >50% excess body weight at ≥2 years post‑procedure with documented compliance), revision for anatomic failures (e.g., dilated pouch or dilated gastrojejunal stoma) when primary procedure was initially successful and member has been compliant with prescribed nutrition and exercise program, or conversion from an adjustable band to sleeve, RYGB, or BPD/DS for complications not correctable with band manipulation/adjustment/replacement.

ANY of the following

• Adjunctive omentectomy performed solely to improve metabolic outcomes.
• AspireAssist aspiration therapy except where FDA‑approved indications apply and criteria met; 'Band over bypass' (placement of LASGB over prior RYGB) and 'band over sleeve' (LASGB over sleeve gastrectomy).
• Bariatric surgery performed solely to treat idiopathic intracranial hypertension or infertility in persons not meeting standard medical necessity criteria for obesity surgery.
• Bariatric surgery for treatment of type 2 diabetes in persons with BMI < 35 kg/m2 (except when meeting updated specialty guidelines and payer‑specific diabetes surgery criteria if present).
• Conversion of sleeve gastrectomy to Roux‑en‑Y gastric bypass for treatment of bile reflux, and conversion to sleeve gastrectomy for hypoglycemia post‑RYGB.
• Duodenal‑jejunal bypass liners and endoscopic gastrointestinal bypass devices (e.g., EndoBarrier, ValenTx), NOTES techniques for bariatric surgery (including TORe, ROSE as primary NOTES bariatric procedures), intragastric balloons (except FDA‑cleared devices when used per indication), mini‑sleeve gastrectomy, laparoscopic gastric plication (LGCP), restorative obesity surgery endoluminal (ROSE), transoral gastroplasty, use of endoscopic closure devices (OTSC, OverStitch, StomaphyX) as primary NOTES bariatric procedures, and other novel devices or procedures lacking sufficient peer‑reviewed evidence.
• Open adjustable gastric banding in contexts not meeting established criteria, prophylactic mesh placement for prevention of incisional hernia after open bariatric surgery, prophylactic pyloroplasty via botulinum toxin injection following LSG, vagus nerve blocking (VBLOC/Maestro) outside FDA‑cleared indications, loop gastric bypass and mini‑gastric bypass due to safety concerns and limited evidence, and Silastic ring vertical gastric bypass (Fobi pouch).
• Measurement of serum C‑reactive protein as a routine predictor for complications following bariatric surgery (insufficient evidence to support routine use).

ANY of the following

• Routine cholecystectomy performed in concert with elective bariatric procedures is considered medically necessary given high incidence of gallbladder disease after bariatric surgery.
• Routine liver biopsy during bariatric surgery is considered not medically necessary in the absence of signs or symptoms of liver disease (e.g., elevated liver enzymes, hepatomegaly, imaging suggesting cirrhosis). Biopsy may be indicated selectively for suspected cirrhosis or when noninvasive testing suggests advanced fibrosis/NASH.

ALL of the following

• Meets BMI and comorbidity thresholds as described in initial bariatric surgery criteria (BMI criteria, comorbidity documentation).
• Documentation of prior attempts at non‑surgical weight loss and participation in an intensive multicomponent behavioral intervention (program documentation, ≥12 sessions within 2 years, or program records substituting for medical records).
• Preoperative evaluation including screening for OSA (or documented diagnosis), appropriate medical clearance, and assessment for perioperative risk (ASA classification).
• Preoperative nutritional assessment and plan, including assessment for micronutrient deficiencies and counseling by registered dietitian when indicated; plan for lifelong supplementation and follow‑up as appropriate.
• For adolescents, criteria include completion of skeletal growth, failure of organized weight‑loss attempts (generally ≥6 months), severe obesity (BMI ≥40) with severe comorbidity or super‑obesity (BMI ≥50) with less severe comorbidity, referral to multidisciplinary pediatric bariatric team, and performance at centers able to collect long‑term outcomes data.

ALL of the following

• Bariatric surgery may be considered for adolescents who have completed bone growth (typically ≥13 years for girls and ≥15 years for boys).
• Candidates should have severe obesity (BMI ≥40) with severe comorbidities or super‑obesity (BMI ≥50) with comorbidities that may be remedied by weight loss, and should have failed organized weight‑loss attempts (generally ≥6 months).
• Referral should be to centers with multidisciplinary pediatric/adolescent weight management teams experienced in the unique needs of adolescents, with capacity to collect long‑term outcomes and provide comprehensive perioperative and long‑term follow‑up.

ALL of the following

• Medical records must document the patient's participation and compliance with an intensive multicomponent behavioral intervention (program name, dates, attendance, progress). Program records from recognized commercial programs (e.g., Weight Watchers, Jenny Craig, OptiFast) may substitute when available.
• Physician documentation of preoperative assessment, prescribed interventions, and progress toward weight‑loss goals (including counseling on diet, physical activity, and behavioral strategies).
• Comprehensive psychological evaluation by a licensed psychologist or psychiatrist is required for candidates with history of severe psychiatric disturbance, active substance abuse, or other psychosocial factors that may impair informed consent or postoperative compliance.

ANY of the following

• Routine liver biopsy at the time of bariatric surgery is not medically necessary in the absence of clinical or laboratory signs of liver disease. Selective biopsy may be indicated when suspected cirrhosis, unexplained hepatic abnormalities, or noninvasive testing (FibroScan, FibroTest/ActiTest, MRE, ELF) suggests advanced fibrosis or NASH.
• Noninvasive tests (FIB‑4, NAFLD Fibrosis Score, transient elastography [FibroScan], magnetic resonance elastography) can be used as first‑line tools to identify advanced fibrosis; TE and MRE are useful at referral centers to select patients for biopsy.

ANY of the following

• RYGB: Considered the procedure of choice in many settings due to durable weight loss and comorbidity resolution; long‑limb RYGB may be used for super‑obese patients. Associated risks include nutritional deficiencies (iron, B12, calcium) and potential for anastomotic complications; laparoscopic approach has lower mortality and faster recovery but differing complication profiles compared with open surgery.
• Sleeve gastrectomy: Increasingly used; evidence shows substantial short‑ to mid‑term weight loss. Considered an approved bariatric procedure by ASMBS though long‑term data are limited. May be used as first‑stage procedure for high‑risk/super‑obese patients; conversion to RYGB is a treatment option for refractory GERD when criteria are met.
• LASGB (adjustable gastric band): Minimally invasive and adjustable, but associated with lower long‑term weight loss than RYGB and high reoperation/band‑removal rates; may be appropriate in selected patients and for salvage after prior RYGB in select circumstances but carries substantial revision risk.
• Biliopancreatic diversion / Duodenal switch (BPD/DS): Produces greatest weight loss but with higher risk of long‑term nutritional deficiencies and requires lifelong follow‑up; may be considered for super‑obese patients in experienced centers.
• Mini/loop gastric bypass and single‑anastomosis (e.g., mini gastric bypass, OAGB): Evidence limited and safety concerns (bile reflux) exist; regarded as investigational or requiring caution in adoption by some guidelines.
• Endoscopic bariatric therapies (IGB, ESG, AspireAssist, TORe, endoscopic suturing, EndoBarrier, OverStitch, StomaphyX): Some FDA‑cleared devices (certain IGBs, AspireAssist) exist with short‑term efficacy; overall long‑term durability and comparative effectiveness vs surgical procedures remain limited. TORe and endoscopic revision techniques may reduce weight regain after RYGB in the short term but require further long‑term evidence and are often considered investigational when used as primary NOTES bariatric procedures.

ANY of the following

• Systematic reviews and some randomized and observational studies show sleeve gastrectomy produces substantial short‑term weight loss and comorbidity improvements; evidence suggests greater weight loss than LASGB and similar short‑term weight loss compared with RYGB in limited trials, but long‑term comparative data are limited.
• ASMBS considers sleeve gastrectomy an approved bariatric procedure, particularly useful as a first‑stage operation in high‑risk or super‑obese patients; professional organizations emphasize need for long‑term outcome data and monitoring for complications such as leaks, strictures, and reflux.

ANY of the following

• Loop/mini gastric bypass procedures have limited high‑quality evidence (primarily case series) and raise concerns about bile reflux and marginal ulceration; many surgeons favor Roux‑en‑Y modifications to reduce reflux risk. These techniques are generally considered investigational or used with caution pending robust comparative trials.

ANY of the following

• LASGB has documented sustained weight loss in many patients but generally less than RYGB and with higher rates of reoperation and device‑related complications (slippage, erosion, need for replacement). CMS and other assessments have supported LASGB in selected patients but long‑term revision rates should be considered.

ANY of the following

• Randomized trials show IGBs can increase short‑term weight loss versus diet alone, but weight regain commonly occurs after removal; FDA has approved specific IGB systems with limited indications and recommended removal at specified durations (typically 6 months). Serious adverse events including rare deaths have been reported and safety surveillance continues.
• Systematic reviews indicate moderate improvements in metabolic parameters with IGBs but limited long‑term durability and potential for serious adverse events (gastric perforation, obstruction).

ANY of the following

• Limited evidence from small case series and one prematurely terminated randomized trial indicates StomaphyX did not meet predefined efficacy endpoints for revisional therapy; current evidence is insufficient to support routine use.

ANY of the following

• Professional guidance (ACOG) states bariatric surgery should not be considered as a treatment for infertility. Pregnancy after bariatric surgery requires appropriate counseling and timing considerations to optimize maternal and fetal outcomes.

ANY of the following

• Case series and small observational studies suggest improvement or resolution of IIH symptoms and papilledema after bariatric surgery in many patients, but evidence is limited (Class IV) and prospective controlled studies are needed before surgery is recommended solely for IIH outside established obesity criteria.

ANY of the following

• Randomized trials and observational studies demonstrate bariatric surgery (RYGB, sleeve, BPD/DS) is superior to medical/lifestyle therapy for weight loss and type 2 diabetes remission in appropriately selected patients, including some lower‑BMI patients in metabolic surgery trials; however, long‑term 'hard' outcomes and durability in lower‑BMI populations require further study.
• Systematic reviews indicate procedures that include malabsorptive components (BPD/DS) yield greater weight loss and diabetes remission but with higher nutritional risks; restrictive procedures yield less weight loss but fewer metabolic complications. Professional consensus statements (e.g., DSS‑II, ASMBS) have updated consideration of metabolic surgery thresholds for T2DM where evidence supports benefit in selected lower‑BMI patients, with ethnicity‑specific BMI adjustments (−2.5 kg/m2 for Asian patients).

ALL of the following

• Bariatric/metabolic surgery may be considered for treatment of T2DM in patients meeting established obesity surgery criteria (BMI ≥35 kg/m2 with inadequately controlled hyperglycemia) and, in selected cases, for patients with BMI 30.0–34.9 kg/m2 when hyperglycemia is inadequately controlled despite optimal medical therapy, consistent with international consensus statements and specialty guideline recommendations; ethnicity‑specific BMI adjustments apply (reduce thresholds by 2.5 kg/m2 for Asian patients).
• Patient selection should consider glycemic control, duration of diabetes, comorbidity profile, and the risks/benefits of surgery with requirement for lifelong follow‑up and monitoring for nutritional deficiencies.

ANY of the following

• Transoral outlet reduction (TORe) using endoscopic suturing devices has randomized sham‑controlled evidence showing modest but significant short‑term weight loss/stabilization after RYGB with dilated GJA; results are procedure‑ and device‑dependent and longer‑term durability is under investigation.
• Endoscopic suturing and plication techniques (ESG, endoscopic sleeve gastroplasty, OverStitch, ROSE, StomaphyX) show promising early results in small studies/series but lack large randomized long‑term comparative data; some devices have limited or failed trials.

ANY of the following

• VBLOC (vagal nerve blocking) has mixed trial results; FDA approved indications are narrow and evidence for broad use is insufficient. Endoscopic liners (EndoBarrier) showed short‑term weight loss but device complications and explantation limited adoption. AspireAssist has FDA approval for specific indications with demonstrated weight loss but requires careful patient selection due to contraindications and potential device‑related complications.

ANY of the following

• Emerging procedures (ESG, endoscopic sleeve gastroplasty, SADI‑S, SIPS, mini procedures) show varied short‑term weight loss and comorbidity improvements in cohort studies and early trials; many societies recommend cautious adoption and collection of outcomes through registries and high‑quality trials to establish long‑term safety and effectiveness.

ANY of the following

• FDA approvals (e.g., ReShape Dual Balloon, Orbera, AspireAssist, Maestro VBLOC) do not alone constitute broad coverage; payer coverage decisions consider trial evidence, safety signals (including post‑market reports), indications, and clinical benefit versus alternatives.

ALL of the following

• Conversion of sleeve gastrectomy to Roux‑en‑Y gastric bypass is considered medically necessary for treatment of symptomatic GERD when: (1) reflux is documented by abnormal 24‑hour pH monitoring or endoscopically proven esophagitis performed after the sleeve gastrectomy; and (2) symptoms persist despite optimal medical therapy including behavioral modification and at least one month of maximum PPI therapy.
• When performed primarily for treatment of reflux that meets these criteria, conversion is not considered repeat bariatric surgery for coverage purposes.

ANY of the following

• SILSG is considered investigational/experimental when performed to achieve outcomes beyond those of conventional multi‑port laparoscopic sleeve gastrectomy due to limited evidence; available series suggest feasibility but RCTs are lacking to demonstrate superiority or equivalent safety in routine practice.

ANY of the following

• Routine prophylactic mesh placement at closure after open bariatric surgery is considered investigational due to insufficient high‑quality evidence; some meta‑analyses suggest reduced incisional hernia risk but further high‑quality studies (including laparoscopic contexts) and cost‑utility analyses are needed.

ANY of the following

• SADI‑S/SIPS and other single‑anastomosis duodeno‑ileal procedures are increasingly reported with promising weight loss and diabetes outcomes but long‑term data and standardized technique reporting are limited. These procedures may be considered in the context of clinical protocols or in experienced centers with registry reporting and long‑term follow‑up, and adoption should follow ASMBS guidance emphasizing cautious implementation and nutritional monitoring.

ANY of the following

• Professional societies (ASMBS, AACE, DSS‑II) provide evolving guidance recognizing metabolic benefits of bariatric procedures for T2DM and endorsing certain newer procedures with caution; they emphasize requirement for long‑term outcome data, registry reporting, and center expertise.

ANY of the following

• High‑quality randomized trials demonstrate superiority of bariatric/metabolic surgery over medical therapy for T2DM remission and glycemic control in selected patients; observational data support reductions in macrovascular events and durable weight loss for many procedures but comparative safety profiles and long‑term outcomes vary by procedure type.

ANY of the following

• The NIH Consensus (1998) and multidisciplinary task groups have informed candidate selection emphasizing prior medical therapy failure, documentation of BMI thresholds and comorbidities, and preoperative commitment to long‑term follow‑up. Intensive multicomponent behavioral interventions are recommended preoperatively (commonly ≥12 sessions) to assess commitment and promote pre‑surgical weight loss goals (eg, 5–10% or 10% as initial target).
• Noninvasive testing for NAFLD/NASH (FIB‑4, NFS, transient elastography, MRE, serum biomarker panels) is useful to screen for advanced fibrosis; liver biopsy remains gold standard but is recommended selectively rather than routinely during bariatric surgery absent clinical indicators of liver disease.
• Endoscopic bariatric therapies and revisional endoscopic procedures (TORe, ESG, OverStitch) are promising minimally invasive options for management of weight regain or as primary therapies in selected patients, but long‑term durability and comparative effectiveness versus surgical approaches remain under study; society guidance recommends registry reporting and further RCTs.
• Emerging procedures (SADI‑S, SIPS, mini/one‑anastomosis procedures) show encouraging weight loss and metabolic outcomes in cohort series, but heterogeneity of techniques, variable follow‑up, and concerns about nutritional deficiencies warrant cautious adoption and further long‑term comparative research.