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ModifiedAmbetter NevadaPolicy CP.MP.37

Bariatric Surgery (Coverage Criteria)

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Defines medical necessity, preoperative requirements, repeat/conversion surgery criteria, investigational and not medically necessary bariatric procedures for members of Ambetter Nevada/Centene-affiliated health plans.

Policy Summary

PayerAmbetter Nevada

PolicyBariatric Surgery (Coverage Criteria)

Policy CodePolicy CP.MP.37

Change TypeMaterial updates to criteria, codes, and procedure scope

Effective Date

Next Review Date

Key ActionObtain prior authorization demonstrating age/BMI criteria and required preoperative evaluations (medical clearance, nutritional evaluation, and age‑appropriate psychiatry/psychology consultation) within six months.

SourceLink

POLICY UPDATE CHANGES

Single-anastomosis duodenoileal bypass (SADI)/SADI-S was added to the Description and to coverage criteria; CPT code 43999 was added for SADI-S.

BMI thresholds and indications were updated for adults including lower thresholds for South Asian, Southeast Asian, and East Asian adults; Type 2 diabetes moved to absolute co-morbidity; multiple comorbidity and preoperative evaluation criteria were revised.

One-anastomosis gastric bypass was removed from investigational procedure list; LAP-BAND criteria for BMI 30–35 removed; several CPT codes (0312T-0317T) were removed previously and some codes were moved to not medically necessary.

6 monthsrequired evaluations

>30procedure and billing codes referenced

SADI-Sprocedure newly added

ethnic-specificBMI thresholds revised

severalnot medically necessary

Coverage Criteria

COVERAGE CRITERIA — Covered when ALL of the following are met

Covered when ALL of the following are met:

ALL of the following

I.A. Medical history: Age and body mass index (BMI) criteria are met: - For adults (≥ 18 years): either • BMI ≥ 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults, or ≥ 35 kg/m2 for all other ethnicities when LAGB, LSG, RYGB, SADI/SADI-S, or BPD-DS/BPD-GRDS is requested; OR • BMI ≥ 27.5 and < 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults, or ≥ 30 and < 35 kg/m2 for all other ethnicities when LAGB, LSG, RYGB, SADI/SADI-S, or BPD-DS/BPD-GRDS is requested AND at least one of the following: type 2 diabetes mellitus OR an obesity-related comorbidity that has not improved despite nonsurgical weight loss methods (examples: hypertension; dyslipidemia; obstructive sleep apnea; obesity-hypoventilation syndrome; nonalcoholic fatty liver disease/nonalcoholic steatohepatitis; pseudotumor cerebri; coronary artery disease; gastroesophageal reflux disease; asthma; venous stasis disease; bone and joint diseases; disqualification from other specialty surgeries due to obesity; chronic kidney disease; infertility; polycystic ovarian syndrome; atrial fibrillation; heart failure).
I.A. Pediatric criteria: Age < 18 years: LSG or laparoscopic RYGB requested, and BMI ≥ 35 kg/m2 or ≥ 120% of the 95th percentile (whichever is lower).

Policy Summary

PayerAmbetter Nevada

PolicyBariatric Surgery (Coverage Criteria)

Policy CodePolicy CP.MP.37

Change TypeMaterial updates to criteria, codes, and procedure scope

Effective Date

Next Review Date

SourceLink

On This Page

COVERAGE CRITERIA — Repeat or conversion surgery

Repeat or conversion surgery is covered when ONE of the following indications is met and all further listed conditions are satisfied:

ANY of the following

To correct complications from a previous bariatric surgery (e.g., obstruction or strictures); conversion surgeries to LSG or RYGB for adults or adolescents, or BPD-DS for adults.
Conversion from LAGB to LSG, RYGB, SADI-S, or BPD-DS; or revision of a primary procedure that has failed due to dilation of the gastric pouch when all of the following are met: 1. All initial bariatric procedure criteria (I.A and I.B) are met again; 2. Previous surgery for morbid obesity was at least 2 years prior to the repeat procedure; 3. Weight loss from the initial procedure was < 50% of the member's excess body weight at the time of the initial procedure; 4. If conversion is requested due to removal of an eroded laparoscopic adjustable band, at least 2 months have passed between band removal and the subsequent bariatric procedure; 5. Documented compliance with previously prescribed postoperative nutrition and exercise program; 6. Supporting documentation includes a clinical explanation of why the prior procedure failed.
Conversion of sleeve gastrectomy (SG) to RYGB for treatment of gastroesophageal reflux disease (GERD) when anti-reflux medical therapy has been tried and failed.
Conversion of SG to RYGB or BPD-DS as a bridging procedure for patients with BMI ≥ 50 kg/m2.

Procedures considered investigational or not medically necessary include, but are not limited to: distal (very long limb) gastric bypass; mini/one-anastomosis (one-anastomosis or omega loop) gastric bypass; laparoscopic re-sleeve gastrectomy performed for a primarily too-large or dilated pouch; Fobi pouch; laparoscopic greater curvature plication (gastric imbrication); stomach aspiration therapy (e.g., AspireAssist); endoscopic suture revisions post-bariatric surgery; gastric plication/endoluminal vertical gastroplasty; endoscopic gastrointestinal bypass devices; endoscopic sleeve gastroplasty; transoral endoscopic surgery; vagus nerve blocking (e.g., Maestro); gastric balloon devices (e.g., ReShape Duo, Orbera, Obalon).

Examples of procedures considered not medically necessary include: biliopancreatic diversion (Scopinaro BPD); jejunoileal bypass (JIB); vertical banded gastroplasty (VBG); gastric pacing/gastric electrical stimulation; gastric wrapping.

CPT and other codes that do not support medical necessity include (examples): 43290, 43291, 43632, 43647, 43648, 43842, 43847, 43881, 43882, 64590, 64595.

Procedure and Billing Codes

Covered CPT Codes (selection)CPTCovered

43644	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less).
43645	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption.
43770	Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components).
43771	Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only.
43772	Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only.
43773	Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only.
43774	Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components.
43775	Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy).
43843	Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty.

Covered CPT Codes (additional)CPTCovered

43845	Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch).
43846	Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy.
43848	Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure).
43860	Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy.
43865	Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy.
43886	Gastric restrictive procedure, open; revision of subcutaneous port component only.
43887	Gastric restrictive procedure, open; removal of subcutaneous port component only.
43888	Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only.
43999	Unlisted procedure, stomach.

CPT Codes that do not support medical necessityCPTNot Covered

43290	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon.
43291	Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s).
43632	Gastrectomy, partial, distal; with gastrojejunostomy.
43647	Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum.
43648	Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum.
43842	Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty.
43847	Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption.
43881	Implantation or replacement of gastric neurostimulator electrodes, antrum, open.
43882	Revision or removal of gastric neurostimulator electrodes, antrum, open.
64590	Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling.

1–10 of 11

1/2

HCPCS Codes that support medical necessityHCPCSCovered

S2083

Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline.

BMI — Age >18: Primary procedure thresholds

Age and BMI (adult)Age >18: BMI ≥32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults OR BMI ≥35 kg/m2 for all other ethnicities when primary procedures (LAGB, LSG, RYGB, SADI/SADI-S, BPD-DS/BPD-GRDS) are requested.

Lower-BMI indication with comorbidityAge >18: BMI ≥27.5 and <32.5 kg/m2 for South/Southeast/East Asian adults OR ≥30 and <35 kg/m2 for other ethnicities when at least one listed comorbidity (eg, Type 2 DM, hypertension, dyslipidemia, OSA) is present.

Adolescent threshold (age <18)Age <18: BMI ≥35 kg/m2 or ≥120% of the 95th percentile (whichever is lower) — see policy for full pediatric criteria.

BMI thresholds — ethnicity and comorbidity adjustments

Ethnicity-specific lower cutoffsPolicy explicitly updates BMI thresholds to include lower cutoffs for South Asian, Southeast Asian, and East Asian adults (examples: ≥32.5 kg/m2 vs ≥35 kg/m2 for primary procedures).

Examples of alternative thresholdsFor adults with qualifying comorbidities: BMI ≥27.5 to <32.5 kg/m2 (South/Southeast/East Asian) or BMI ≥30 to <35 kg/m2 (other ethnicities).

Documentation implicationBMI must be documented as part of prior authorization and meet the updated ethnicity- and comorbidity-specific thresholds in I.A.1.a.i–ii.

Provider Actions & Administrative Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for bariatric surgery. Requests must demonstrate that all applicable medical history and preoperative evaluation criteria in Sections I.A and I.B of the policy are met prior to authorization.

Prior authorization required for procedures listed in the policy (see CPT/HCPCS code lists).
Authorization must include documentation that all listed medical-history criteria (age/BMI thresholds, comorbidities) and preoperative evaluations/clearances have been satisfied.

Prior Authorization

Prior Authorization — Procedure and Device Codes

Prior authorization is required for the bariatric CPT and HCPCS codes identified in this policy. Use the listed codes as supporting documentation for medical necessity when submitting authorization requests.

Covered/Supporting CPT examples include: 43644, 43645, 43770–43775, 43843, 43845, 43846, 43848, 43860, 43865, 43886–43888, 43999.
Supporting HCPCS example: S2083 for gastric band adjustment.
Providers must reference current CPT/HCPCS descriptions and include operative reports and supporting documentation to justify the selected codes.

Denial Risk

Denial Triggers

Requests that do not meet the policy criteria or lack required documentation may be denied. Common denial triggers include not meeting age or BMI thresholds, missing required preoperative evaluations or clearances, or absence of required supporting clinical documentation.

Failure to demonstrate required age and BMI criteria per Section I.A.
Missing medical evaluation and clearance (PCP, cardiology, pulmonology where applicable) or missing documentation of failed nonsurgical weight loss attempts when required.
Absence of required supporting documentation such as nutrition evaluation, behavioral health assessment, or explanations for prior procedure failure or conversions.

Denial Risk

Denial Risk from Coverage Exclusions or Limits

Coverage decisions are subject to all terms, conditions, exclusions and limitations of the member's coverage document. Even if policy criteria are met, benefits are not guaranteed — authorization and payment remain subject to plan contract, member eligibility, benefit limits, and applicable exclusions.

Ensure the requested service is a covered benefit under the member's specific plan before proceeding with authorization submission.
State Medicaid provisions override this policy where applicable — consult the state Medicaid manual for conflicts.

Documentation Required

Documentation and Applicability Reminder

Provide complete documentation to support medical necessity and to facilitate authorization and claims processing. The policy is a guide; providers must exercise professional judgment and submit all relevant clinical records.

Required documentation generally includes: medical evaluation from a non‑surgeon physician with recommendation and medical clearance, nutrition evaluation, behavioral/psychological assessment, operative reports, and records of prior weight‑loss treatments.
Include current CPT/HCPCS codes with corresponding supporting clinical documentation and reference up‑to‑date code descriptions when submitting claims.
This clinical policy is informational and does not replace provider clinical judgment or the member's plan contract.

Step Therapy

Step Therapy (Informational)

Step therapy/other utilization management strategies: informational only. This policy references generally accepted guidelines and literature; it does not mandate a specific step‑therapy sequence for bariatric surgery but payers may apply plan‑level utilization management processes as appropriate.

No specific step‑therapy requirement is mandated by this policy.
Health Plans may apply additional administrative requirements (e.g., prior authorization, medical necessity review) consistent with plan procedures.

Definitions

Restrictive procedures

DefinitionRestrictive procedures create a small stomach pouch to limit food intake and promote weight loss.

ExamplesLaparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) are examples of restrictive procedures.

Clinical noteProcedure selection should consider BMI, comorbidities, patient goals, and surgeon expertise; LSG is commonly used with a favorable safety profile.

Malabsorptive procedures

DefinitionMalabsorptive procedures bypass portions of the stomach and/or small intestine, resulting in decreased digestion and nutrient absorption.

ExamplesDuodenal switch and biliopancreatic diversion with duodenal switch (BPD-DS) are examples of malabsorptive procedures.

Clinical considerationsThese procedures have both malabsorptive and restrictive components and are complex, performed at specialized centers.

Endoluminal vertical gastroplasty / gastric plication

Procedure descriptionEndoluminal vertical gastroplasty/gastric plication is an endoscopic suturing approach that suctions anterior and posterior stomach walls together and secures them to create a restrictive tube similar to sleeve gastrectomy.

Technique examplesApproaches include suctioning and fixation with stapler or T-fastener devices to form a tubular stomach.

Outcomes noteConsidered an endoscopic restrictive technique; long-term outcomes compared with surgical sleeve gastrectomy are limited in the literature.

Endoscopic gastrointestinal bypass devices (EGIBD)

DefinitionEndoscopic gastrointestinal bypass devices (EGIBD) are barrier devices deployed to prevent absorption in the proximal small intestine (examples: ValenTX, EndoBarrier).

Durability/outcomesData are lacking about the longevity of endobarriers and outcomes after removal; long-term effectiveness and durability remain uncertain.

Policy stanceEGIBD and certain endoscopic devices are listed among procedures with limited evidence and are considered investigational or not medically necessary in parts of the policy.

SADI-S (single-anastomosis duodeno-ileal bypass with sleeve gastrectomy)

DefinitionSADI-S (single-anastomosis duodeno-ileal bypass with sleeve gastrectomy) is a bariatric procedure combining sleeve gastrectomy with a single-anastomosis intestinal bypass.

Policy updateSADI/SADI-S was added to the Description and to coverage criteria (I.A.1.a.i and I.A.1.a.ii) in recent revisions; CPT 43999 was added operationally for SADI-S.

Guidance and evidenceReferenced guidance includes NICE IPG569 and ASMBS/IFSO statements; see policy references for supporting literature and position statements.