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ModifiedAlliance HealthPolicy 1A-15

Bariatric Surgery Coverage Criteria

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Defines coverage, eligibility, and procedural descriptions for bariatric surgery under North Carolina Medicaid (including EPSDT considerations) and who may be affected (adult beneficiaries and case-by-case pediatric EPSDT).

Policy Summary

PayerAlliance Health

PolicyBariatric Surgery Coverage Criteria (Clinical Coverage Policy No: 1A-15)

Policy CodePolicy 1A-15

Change TypeAdded accreditation requirement for prior approval (material change)

Effective Date

Last ReviewOct 1, 2024

Next Review Date

Key ActionSubmit proof of MBSAQIP facility accreditation with each prior approval request to avoid denial.

SourceLink

POLICY UPDATE CHANGES

Facility MBSAQIP accreditation must be submitted with each prior approval request beginning November 1, 2023.

Effective November 1, 2023, facilities will be required to have MBSAQIP accreditation and proof must be submitted with each prior approval request; PA requests without proof will be denied effective that date.

Attachment A CPT code tables (C1 and C2) were combined into one table and table titles deleted.

Updated claim billing guidance to require Institutional Claims to follow National Uniform Billing Guidelines and National Coding Guidelines.

Nov 1, 2023MBSAQIP effective date

Age ≥18Adult eligibility

BMI ≥40Morbid obesity threshold

12 monthsPre-request conservative therapy

6 monthsPre-op evaluations window

ONEProcedures per lifetime

Coverage Criteria for Bariatric Surgery

Covered Bariatric Procedures (descriptions)

Covered when medical necessity and eligibility criteria (see Eligibility and EPSDT provisions) are met. Procedures described in the policy include:

procedure_list: Roux-en-Y gastric bypass (short limb ≤150 cm; long-limb >150 cm may be considered for BMI ≥55 kg/m2); Adjustable gastric banding (inflatable adjustable band creating a small gastric pouch; covered for BMI <50 kg/m2; case-by-case if ≥50 kg/m2); Biliopancreatic diversion with or without duodenal switch (primarily malabsorptive; considered for BMI ≥50 kg/m2); Laparoscopic sleeve gastrectomy (LSG) (restrictive, reduces stomach ~25% of original size); Revision of bariatric surgery for complications or failure.

Each procedure has specific anatomic/technical descriptions (e.g., roux limb length guidance for Roux-en-Y).

Eligibility and EPSDT exceptions

Standard adult and pediatric eligibility rules and EPSDT special provisions:

standard_eligibility: Beneficiary enrolled in NC Medicaid; adults (age ≥ 18 years) are eligible under standard policy; beneficiaries under 18 (and under 21 for EPSDT) are considered on a case-by-case basis under EPSDT when documentation shows the service is medically necessary to correct or ameliorate a condition.

Policy Summary

PayerAlliance Health

PolicyBariatric Surgery Coverage Criteria (Clinical Coverage Policy No: 1A-15)

Policy CodePolicy 1A-15

Change TypeAdded accreditation requirement for prior approval (material change)

Effective Date

Last ReviewOct 1, 2024

Next Review Date

Key ActionSubmit proof of MBSAQIP facility accreditation with each prior approval request to avoid denial.

SourceLink

On This Page

age >= 18 for standard adult eligibility

EPSDT does not eliminate prior approval requirements and may allow exceptions to policy limits when documentation meets EPSDT criteria.

Initial bariatric surgery coverage — Covered when ALL of the following are met

Covered when ALL of the following are met

Primary coverage prerequisites

Allowed primary procedures (one of): One of the listed bariatric procedures must be selected: Gastric bypass with roux limb ≤150 cm; Adjustable gastric banding (BMI <50 kg/m2; case-by-case if ≥50); Biliopancreatic diversion with/without duodenal switch (consider for BMI ≥50); Gastric bypass with roux limb >150 cm (long-limb) (consider for BMI ≥55); or Laparoscopic sleeve gastrectomy (LSG).
See procedure-specific BMI considerations
Duration and conservative therapy: Beneficiary must have met ALL criteria in subsection 3.2.1 for the past 12 calendar months prior to the request, including unsuccessful medical treatment for clinically severe or morbid obesity for at least 12 months with at least three calendar months of supervised treatment and monthly encounter documentation.12 months
Monthly documentation requirements described in policy
Required comorbid conditions (at least one): Diagnosis of extreme or morbid obesity (BMI ≥40, or BMI ≥35 with a significant obesity-related comorbid condition) OR presence of at least one specified comorbid condition such as type 2 diabetes mellitus, coronary artery disease, severe osteoarthritis limiting motion, significant respiratory insufficiency or sleep apnea, pulmonary hypertension, refractory hypertension, severe dyslipidemia (e.g., hypercholesterolemia >240 mg/dL, hypertriglyceridemia >400 mg/dL, LDL >160 mg/dL, HDL <40 mg/dL despite therapy), metabolic syndrome/NASH, or other documented obesity-related conditions.
Comorbidities must be documented and, where applicable, refractory to medical therapy
Additional documentation: Health record documentation must substantiate: A) unsuccessful medical treatment for 12 months including ≥3 months supervised care; B) monthly encounter notes documenting weight >100 lb or 45 kg above ideal with height documented, caloric requirements and modified eating behaviors, and measurable prescribed activity; C) no correctable endocrine cause for obesity; and D) treatment of listed medical conditions.
Surgeon must submit all supporting health records with prior approval request
Multidisciplinary evaluations: Face-to-face comprehensive dietician/nutritionist evaluation within six months and psychological evaluation by a licensed professional within six months documenting absence of significant psychopathology and beneficiary suitability for surgery, including ability to comply with postoperative care.6 months
Evaluations must be individual face-to-face encounters (not group)

Medically necessary statement: Requesting surgeon must perform a complete history & physical when all pre-surgical requirements are met, documenting current weight, height, BMI, relevant labs (including thyroid), medication list, and appropriate pre-op workup.

Include required pre-op studies in prior approval submission

Surgical revision coverage — Revision covered when

Revision covered when

Revision for complications: Revision of a primary bariatric procedure is covered for documented perioperative or late complications when the beneficiary meets one of the listed conditions: weight loss of 20% or more below ideal body weight; esophagitis unresponsive to nonsurgical treatment; hemorrhage/hematoma complicating a procedure; excessive bilious vomiting; complications of intestinal anastomosis and bypass; stomal dilation confirmed by endoscopy; slippage of adjustable gastric band not correctable with manipulation; stricture; obstruction; erosion; staple-line failure; or non-absorption (e.g., hypoglycemia or malnutrition).

Provide documentation of the specific complication and supporting studies

Revision for failure: Revision for failed primary procedure is covered when pouch dilation is confirmed by upper GI exam or endoscopy producing weight gain of 20% or more, provided the primary procedure was previously successful in inducing weight loss and the beneficiary has been compliant with prescribed nutrition and exercise; submit pre-surgery, nadir, and current weights/BMI and surgeon statement of compliance.20% weight gain

Compliance and weight history must be documented

Administrative and prior authorization requirements

Covered bariatric procedures require provider eligibility, accreditation, compliance, and prior approval documentation.

Provider eligibility and credentials: Providers must meet Medicaid qualifications for participation, have a signed and current DHHS Provider Administrative Participation Agreement, and bill only for procedures within the scope of their clinical practice.

From provider eligibility section

Facility accreditation for PA: Facilities must have MBSAQIP accreditation and submit proof with each prior approval request; prior approval requests submitted without proof of accreditation will be denied effective November 1, 2023.Effective 11/01/2023

Proof of MBSAQIP required with each PA

Prior approval requirements: Prior approval is required before performing bariatric surgery; submit the prior approval request and all supporting health records to the DHHS Utilization Review Contractor. Approval does not transfer to another provider or allow a change in procedure.

Follow NCTracks and DHHS prior approval submission guidance

Compliance with laws and policies: Providers shall comply with applicable federal, state, and local laws (including HIPAA), NC Medicaid clinical coverage policies, provider manuals, and billing guidance; submit claims using the appropriate claim type and report ICD-10-CM/PCS and CPT/HCPCS codes to the highest level of specificity.

Claims and documentation compliance requirements

EPSDT does not require coverage of services that are unsafe, ineffective, experimental, or investigational. For beneficiaries under age 21, an EPSDT exception may permit services that exceed usual policy limits only when the provider documentation demonstrates the service is medically necessary to correct or ameliorate a condition. However, services that are unsafe, ineffective, or investigational remain excluded and will not be required under EPSDT.

Medicaid does not cover procedures performed solely for cosmetic purposes, including surgical removal of excess skin and fat that results from weight loss when done only for cosmetic reasons. Staged procedures are likewise not covered. Refer to the Reconstructive and Cosmetic Surgery policy for criteria that may apply to excessive skin removal following bariatric surgery.

Bariatric surgical procedures are not covered for beneficiaries with a BMI less than 35 kg/m2 except where EPSDT documentation for a beneficiary under age 21 justifies an exception per the EPSDT criteria.

Coverage for adjustable gastric banding and biliopancreatic diversion (with or without duodenal switch) is limited by BMI thresholds: adjustable gastric banding is not covered for beneficiaries with BMI greater than 50 kg/m2, and biliopancreatic diversion with or without duodenal switch is not covered for beneficiaries with BMI less than 50 kg/m2.

Historical policy revisions note that panniculectomy (excision of excessive skin and subcutaneous tissue) was identified as not a covered service effective October 1, 2010. Cosmetic follow-up surgeries and related noncoverage items are addressed in the policy's revision history and in the cosmetic/reconstructive policy cross-reference.

When a beneficiary has Medicare or private insurance, the provider must obtain prior authorization from the primary payor before billing Medicaid. If the primary payor denies the procedure as not medically necessary or the provider did not follow the primary payor's requirements, Medicaid will not pay for the service; a claim must be submitted to the primary payor before Medicaid will consider payment.

Services are not covered when the beneficiary does not meet Section 2.0 eligibility or Section 3.0 medical criteria, when the service duplicates another provider's service, when the service is experimental or part of a clinical trial, or when specific noncoverage items apply (see the listed procedures and conditions in Section 4.2). Providers must confirm eligibility and that all coverage criteria are met before requesting prior approval.

Approval cannot be granted while contraindications exist. The policy lists contraindications that must be resolved and documented in the health record prior to approval, including untreated major depression or psychosis, binge-eating disorders, and current drug or alcohol abuse.

In summary, the policy states general noncoverage rules (e.g., failure to meet eligibility or criteria, duplication of services, experimental treatments) and specific noncoverage criteria (listed excluded procedures, pregnancy/breastfeeding exclusions, preadolescent status, planning pregnancy within two years, lack of demonstrated mastery of healthy habits, and cosmetic-only procedures). Historical revisions further clarify certain noncovered items.

CPT code 43659 (laparoscopic band revision/replacement) is limited in coverage: it is only covered when used for revision of lap banding in which both the gastric band and the subcutaneous port components are to be removed and replaced and when all criteria in Subsection 3.2.4 are met.

Codes, BMI Thresholds, and Coding Rules

Covered bariatric proceduresmixedCovered

not specified	Gastric bypass with roux limb 150 cm or less (Roux-en-Y gastroenterostomy)
not specified	Adjustable gastric banding
not specified	Biliopancreatic diversion with or without duodenal switch
not specified	Gastric bypass with roux limb greater than 150 cm (long-limb Roux-en-Y)
not specified	Laparoscopic sleeve gastrectomy (LSG)

Not covered proceduresmixedNot Covered

not specified	Jejunoileal bypass
not specified	Biliopancreatic diversion with or without duodenal switch for BMI < 50 kg/m2
not specified	Gastric wrapping
not specified	Adjustable gastric banding for BMI > 50 kg/m2
not specified	Jejunocolostomy
not specified	Mini-gastric bypass
not specified	Open sleeve gastrectomy
not specified	Gastric bypass with roux limb greater than 150 cm for BMI < 55 kg/m2
not specified	Bariatric surgical procedures for BMI < 35 kg/m2
not specified	Gastric electrical stimulation

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1/2

Covered CPT/Procedure Codes (historical and Attachment A mentions)CPTCovered

43644	laparoscopic gastric bypass (documented replacement of unlisted 43659 in 2005)
43645	CPT code added to covered codes (07/01/2008 revision)
43770	CPT code added to covered codes (07/01/2008 revision)
43771	CPT code added to covered codes (07/01/2008 revision)
43772	CPT code added to covered codes (07/01/2008 revision)
43773	CPT code added to covered codes (07/01/2008 revision)
43774	CPT code added to covered codes (07/01/2008 revision)
43845	CPT code added to covered codes (07/01/2008 revision)
43847	CPT code added to covered codes (07/01/2008 revision)
43848	CPT code added to covered codes (07/01/2008 revision)

1–10 of 16

1/2

Procedure code mappings / CPT pairsmixed

43644	listed with CPT Code(s) = 43773
43644	listed with CPT Code(s) = 43848
43645	listed with CPT Code(s) = 43774
43645	listed with CPT Code(s) = 43886
43659*	listed with CPT Code(s) = 43775
43659*	listed with CPT Code(s) = 43887
43770	listed with CPT Code(s) = 43845
43770	listed with CPT Code(s) = 43888
43771	listed with CPT Code(s) = 43846
43771	listed with CPT Code(s) = (no mapping provided)

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Unlisted procedure reportingCPT | HCPCS

CPT: unlisted	Follow CPT unlisted procedure instructions and submit special report
HCPCS: unlisted	Follow HCPCS unlisted procedure instructions and submit special report

inv-21: Body Mass Index (BMI) thresholds — clinically severe and morbid

Clinically severe obesityBMI 35-39.9 kg/m2 when accompanied by one or more obesity-related comorbid conditions

Morbid obesityBMI greater than or equal to 40 kg/m2

Most actionable BMI thresholdFor coverage consideration: BMI ≥ 40 kg/m2 or BMI 35-39.9 kg/m2 with significant comorbidity

inv-22: BMI thresholds — examples and procedure-specific BMI requirements

Roux-en-Y standard requirementGastric bypass with roux limb ≤ 150 cm is a covered primary procedure; long-limb Roux-en-Y (roux >150 cm) considered for BMI ≥ 55 kg/m2

Adjustable gastric bandingCovered for beneficiaries with BMI < 50 kg/m2; beneficiaries with BMI ≥ 50 kg/m2 considered case-by-case with medical necessity documentation

Biliopancreatic diversionConsidered only for beneficiaries with BMI ≥ 50 kg/m2 on an individual basis with appropriate documentation

inv-23: Revision failure/complication thresholds (weight change triggers)

Revision for failure — weight gain triggerRevision covered when pouch dilation produces weight gain of 20% or more (documented by upper GI or endoscopy) and prior success then compliance with nutrition/exercise is shown

Revision for excessive weight lossRevision covered when weight loss of 20% or more below ideal body weight is documented as a qualifying complication

Other complication-based revisionsRevision covered for documented perioperative or late complications (eg, hemorrhage, obstruction, erosion, staple-line failure, slippage not correctable)

inv-24: BMI references in limitations context

Not covered below BMI thresholdBariatric surgical procedures are not covered for beneficiaries with BMI less than 35 kg/m2

Procedure-specific noncoverage for high BMIAdjustable gastric banding is not covered for beneficiaries with BMI greater than 50 kg/m2 (per specific exclusions)

Procedure-specific noncoverage for low BMIGastric bypass with roux limb >150 cm is not covered for beneficiaries with BMI less than 55 kg/m2

inv-25: Coding specificity — use highest level of ICD-10 specificity and current edition

ICD-10-CM specificity requirementReport ICD-10-CM and PCS codes to the highest level of specificity that supports medical necessity

Use current editionProviders shall use the current ICD-10 edition and any subsequent editions in effect at the time of service

Refer to code descriptions externallyCode descriptions are not documented in the policy; refer to the applicable ICD-10 edition for exact descriptions

Provider Steps, Prior Authorization, and Documentation

Prior Authorization

Prior approval still required for beneficiaries under 21

If prior approval is required by this policy, beneficiaries under age 21 still require prior approval; providers must follow NCTracks and EPSDT guidance when submitting requests for pediatric beneficiaries.

Prior Authorization

Submit prior approval plus supporting health records

Obtain prior approval before performing bariatric surgery and submit the prior approval request together with all supporting health records and documentation to the DHHS Utilization Review Contractor as required.

A letter from the surgeon alone is not sufficient documentation; submit all health records that substantiate meeting Subsection 3.2 criteria.

Prior Authorization

MBSAQIP accreditation required with each PA

Facilities must have MBSAQIP accreditation and submit proof of that accreditation with each prior approval request; failure to include proof will result in denial beginning November 1, 2023.

Billing Rule

Obtain primary payer prior authorization before billing Medicaid

When a beneficiary has Medicare or private insurance, obtain prior authorization from the primary payor before billing Medicaid; Medicaid is secondary and will only pay remaining coinsurance/deductible if the primary payor approves.

Submit a claim to the primary payor before billing Medicaid; if primary denies as not medically necessary, Medicaid will not pay.

Note

Verify Medicaid enrollment and eligibility each time

Verify each beneficiary's NC Medicaid enrollment and eligibility at the time of service; eligibility category restrictions may make the beneficiary ineligible for bariatric services and services may be denied if eligibility is not verified.

Step Therapy

Document 12 months of supervised conservative therapy

Document 12 months of unsuccessful supervised medical treatment for obesity prior to the request, including at least three months of treatment supervised by a medical provider with monthly encounter notes documenting required elements.

Monthly encounter notes must document: current body weight with at least one height, caloric requirements and modified eating behaviors, and measurable prescribed activity (type, frequency, duration).
The 12-month period must immediately precede the prior approval request.

Prior Authorization

Prior approval does not transfer to another provider or procedure

Prior authorization approvals are not transferable: if the beneficiary changes providers or the planned bariatric procedure is changed, submit a new prior authorization request and meet all policy requirements.

Billing Rule

Medicaid is secondary — follow primary payer obligations

Medicaid will not duplicate primary payer coverage: follow the primary payor's requirements first and obtain any required prior steps from the primary insurer; if the primary payor denies as not medically necessary, Medicaid will not pay.

If primary payer approves and pays, Medicaid is only responsible for remaining coinsurance/deductible.

Documentation Required

Document BMI (kg/m2); pregnancy weight not acceptable

Calculate and document BMI as weight in kilograms divided by height in meters squared (kg/m2); weight gained during pregnancy cannot be used to meet pre-surgical BMI requirements.

Record weight and height used to calculate BMI in the health record.

Documentation Required

Include EPSDT medical necessity documentation for <21

For beneficiaries under 21, include documentation that demonstrates EPSDT medical necessity showing how the requested service will correct or ameliorate a condition; EPSDT does not remove prior approval requirements.

Provider documentation must show how the service meets EPSDT criteria to correct, improve, or prevent worsening of a health problem.

Documentation Required

Submit full H&P and required encounter documentation with PA

Submit complete health records with the prior approval request, including a complete history and physical that documents current weight, height, BMI, pertinent labs (including thyroid), medication list, and appropriate pre-operative workup.

Encounter notes must include beneficiary name on each page, date of service, exclusive purpose, individualized interventions, and beneficiary response.
Appropriate pre-op workup may include chest x-ray, upper GI series, endoscopy, pre-op labs, and ECG; routine pre-admission work-up should be held pending approval.

Documentation Required

Face-to-face dietician/nutritionist evaluation within 6 months

Include a face-to-face comprehensive dietician or nutritionist evaluation performed within six months prior to the request that documents diet history, prior weight-loss management, and the beneficiary's ability to comply with postsurgical care.

Evaluation must be individual (not group) and document history of supervised diets/exercise and ability to comply with lifetime post-surgical requirements.

Documentation Required

Psychological evaluation by licensed professional within 6 months

Include a psychological evaluation by a licensed psychologist, psychiatrist, or licensed clinical social worker within six months prior to the request that documents psychiatric history, current psychological function, eating behaviors, activity level, substance use history, and suitability for surgery.

Evaluation must document absence of significant psychopathology and the beneficiary's ability to comply with postoperative care; inability to comply results in denial.

Denial Risk

Eligibility verification at time of service to avoid denial

Verify beneficiary eligibility before service; services may be denied if the beneficiary is not enrolled in NC Medicaid or eligibility is not verified at time of service.

Denial Risk

Unsafe, ineffective, or experimental services may be excluded

Services that are unsafe, ineffective, or experimental/investigational are excluded and may be denied under EPSDT and general policy; do not request prior approval for excluded services.

Denial Risk

Omit MBSAQIP proof and PA will be denied (effective 11/01/2023)

Prior approval requests submitted without proof of MBSAQIP accreditation will be denied effective November 1, 2023; include facility accreditation documentation with each PA submission.

Denial Risk

Do not submit surgeon summary alone or illegible records

Illegible documentation or a surgeon's summary letter alone is not sufficient for a prior approval request; submit legible encounter notes and full supporting health records.

Encounter notes must meet required elements (name on each page, date, exclusive purpose, individualized intervention, beneficiary response).

Denial Risk

Operational denial risk if MBSAQIP proof missing (11/01/2023)

Operational denials will occur if MBSAQIP accreditation proof is not provided with the prior approval request beginning November 1, 2023; ensure accreditation documentation accompanies every PA submission.

Denial Risk

Primary payor denial prevents Medicaid payment

If the primary payor denies the procedure as not medically necessary or the provider failed to follow the primary payor's requirements, Medicaid will not pay for the services; submit the claim to the primary payor before billing Medicaid.

Medicaid may only pay remaining coinsurance/deductible if the primary payor approves and pays.

Billing Rule

Follow NCTracks and national billing/coding guidance

Comply with NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, clinical coverage policies, obtain appropriate referrals for managed care enrollees, and follow National Uniform Billing and National Coding Guidelines for institutional claims.

Billing Rule

Report diagnosis and procedure codes to highest specificity

Report ICD-10-CM and PCS codes to the highest level of specificity using the current edition and report the most specific CPT/HCPCS/UB revenue code that accurately describes the service; for unlisted services follow CPT/HCPCS instructions and submit a special report when required.

List only the code on claim submissions; use unlisted codes only when no specific code exists and include the required special report.

Background and Context

Bariatric surgery is performed for long-term surgical weight loss management in clinically severe or morbid obesity to reduce morbidity and improve metabolic and organ function. Procedures achieve weight loss by restriction, malabsorption, or both; some procedures (for example, sleeve gastrectomy) also reduce appetite through hormonal changes. Coverage is provided when medical necessity and the policy's eligibility and documentation requirements are met.

Definitions and Terms

inv-48: Body Mass Index (BMI) definition and calculation note

BMI definition and formulaBody Mass Index (BMI) = weight in kilograms divided by height in meters squared (kg/m2)

Pregnancy weight exclusionWeight gained during pregnancy cannot be used to meet pre-surgical BMI requirements

Practical measure noteBMI is considered the most practical measure of a beneficiary's body fat for this policy

inv-49: Clinically Severe Obesity definition — BMI 35-39.9 with comorbidities

DefinitionClinically severe obesity: BMI 35-39.9 kg/m2 with co-morbid conditions

Associated comorbidities examplesComorbid conditions include type 2 diabetes, coronary disease, severe osteoarthritis limiting motion, significant respiratory insufficiency or sleep apnea, pulmonary hypertension, refractory hypertension, severe dyslipidemia, NASH/metabolic syndrome

Coverage contextBeneficiaries meeting this BMI with required documentation of failed conservative therapy for 12 months may be eligible for covered bariatric procedures

inv-50: Morbid Obesity definition — BMI ≥ 40 kg/m2

DefinitionMorbid obesity: BMI greater than or equal to 40 kg/m2

Extreme obesity noteExtreme obesity may be referenced as BMI ≥ 40 or BMI ≥ 35 with a significant comorbid condition for coverage considerations

Coverage implicationBeneficiaries with BMI ≥ 40 who meet documentation and conservative-therapy requirements are eligible for covered bariatric procedures

inv-51: Extreme obesity / BMI thresholds — procedure-specific thresholds referenced

Extreme obesity definitionExtreme obesity defined as BMI ≥ 40 kg/m2, or BMI >35 kg/m2 with a significant obesity-related comorbid condition

Procedure-specific thresholdsCertain procedures have BMI-based thresholds (eg, biliopancreatic diversion considered for BMI ≥50; long-limb Roux-en-Y considered for BMI ≥55; adjustable banding limited to BMI <50 unless case-by-case)

Case-by-case considerationWhen a beneficiary's BMI falls into procedure-specific boundary ranges (eg, adjustable banding at ≥50), individual medical necessity documentation is required

inv-52: EPSDT — definition and applicability to under-21 beneficiaries

EPSDT applicabilityEPSDT (Early and Periodic Screening, Diagnostic, and Treatment) applies to Medicaid beneficiaries under age 21 and may allow exceptions to policy limits when documentation shows medical necessity to correct or ameliorate a condition

Prior approval for under-21If the service requires prior approval, beneficiaries under 21 still require prior approval and providers should follow NCTracks and EPSDT guidance for submission

Case-by-case surgical considerationBeneficiaries under 18 are considered on a case-by-case basis under EPSDT for bariatric surgery eligibility; documentation must demonstrate EPSDT medical necessity

Policy Revision History

11/01/2023operational requirement addedLatest

Effective November 1, 2023, facilities are required to have MBSAQIP accreditation and must submit proof of accreditation with each prior approval request; prior authorization requests submitted without proof will be denied.

03/15/2019template update

Updated policy template language and added PHP contact language for beneficiaries enrolled in a Prepaid Health Plan; policy and attachments revised.

10/01/2015coding and system update

Updated policy template language and added ICD-10 codes to comply with federally mandated implementation effective October 1, 2015.

09/01/2015coverage clarification

Revised multiple sections including Subsection 3.2.1 and added/clarified requirements for dietician/nutrition and psychological evaluations and other coverage criteria.

07/01/2008major revision

Added detailed procedure descriptions and expanded coverage, noncoverage, and prior approval requirements; multiple CPT codes were added to Attachment A as covered codes.

09/01/2004substantive revision

Revised entire policy to change terminology to 'clinically severe' obesity, add BMI requirements and refine comorbidity and duration documentation requirements.

02/01/2005coding change

Replaced unlisted procedure code 43659 with CPT code 43644 for the laparoscopic version of gastric bypass (Roux-en-Y) and added 43644 to covered codes.