Obtain prior authorization and include CPT/HCPCS codes

Prior authorization is required for bariatric procedures that meet medical necessity under this policy. When requesting authorization include the applicable CPT or HCPCS procedure codes (examples of covered codes include 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846, 43848, 43860, 43865, 43886, 43887, 43888, 43999 and HCPCS S2083).

• Include the exact CPT/HCPCS codes for the planned procedure on the prior authorization request.

Verify effective date and plan-specific prior authorization process

This clinical policy is a guide for medical necessity determinations; the Health Plan sets the effective date and may change, amend, or withdraw the policy or prior authorization processes. Providers should verify the policy effective date and follow plan-specific authorization procedures.

• The clinical policy is effective as of the date determined by the Health Plan and the posting date may not be the effective date.
• Health Plan retains the right to change policy, prior authorization requirements, and plan-level administrative procedures.

Follow consolidated preoperative evaluation requirements (I.B.1–I.B.3)

Providers must follow the current consolidated preoperative evaluation requirements now specified in sections I.B.1 through I.B.3; medical evaluation must be documented by a physician other than the surgeon as required by the updated policy language.

• Previous separate preoperative evaluation and medical clearance requirements were removed and replaced with consolidated I.B.1–I.B.3 requirements.
• Documented medical evaluation from a physician other than the surgeon is required per the revised preoperative evaluation language.

No step therapy specified in this policy

No explicit step therapy requirements are stated in the policy chunks reviewed. Providers should not assume any step therapy steps are mandated by this clinical policy but must confirm plan-level requirements if applicable.

• The document states no explicit step therapy requirements in the provided sections.
• Verify any plan-level or contractual step therapy rules separately with the Health Plan.

Document preoperative evaluation per updated I.B.1–I.B.3

Ensure preoperative evaluation documentation complies with the policy’s revised requirements: the prior separate clearance items were replaced by consolidated I.B.1–I.B.3 and must be followed and recorded in the member’s chart.

• Follow the updated I.B.1–I.B.3 preoperative evaluation requirements.
• Document the medical evaluation performed by a physician other than the surgeon as specified.

Comply with plan-level administrative, contractual, and legal requirements

Providers must comply with Health Plan-level administrative policies, contractual terms, and applicable state and federal requirements when submitting claims and seeking authorization; they remain responsible for claims submission and adherence to plan rules.

• Coverage and administration are subject to terms, conditions, exclusions, and limitations of the member’s coverage documents.
• State Medicaid provisions take precedence where they conflict with this clinical policy; follow contractual and regulatory obligations.

Risk of denial when using CPT codes that do not support medical necessity

Claims submitted for bariatric surgery using CPT codes listed in the policy’s 'do not support medical necessity' table are at risk for denial if billed for bariatric surgery coverage.

• Codes at risk for denial include 43290, 43291, 43632, 43647, 43648, 43842, 43847, 43881, 43882, 64590, and 64595.
• Do not submit these codes for bariatric surgery coverage without confirming medical necessity per policy exceptions.

Coverage determinations subject to coverage documents and law

Coverage decisions and benefit administration for bariatric procedures are governed by the member’s coverage documents and applicable laws; this clinical policy does not guarantee payment and may be changed by the Health Plan.

• Decisions are subject to all terms, conditions, exclusions, and limitations of the coverage documents and to state and federal requirements.
• The Health Plan may change, amend, or withdraw this clinical policy at any time; verify coverage and effective dates with the plan.