Blue Cross Blue Shield MA Bariatric Coverage Update

Coverage Criteria for Bariatric Surgery and Related Procedures

Initial bariatric surgery — Class 3 obesity

Covered when ALL of the following are met for adults with Class 3 obesity:

Adult Class 3 BMI: BMI ≥ 40 kg/m2BMI ≥ 40 kg/m2

Applies to adults (age ≥ 18 years)

Failed conservative measures: Failed weight loss by conservative measures (diet, exercise, behavioral changes) as judged by the surgeon

Duration and specifics at surgeon's discretion

Patient selection and program enrollment: Well-informed, motivated patient with acceptable operative risk and enrolled in a multidisciplinary pre-op and post-op program (behavioral health, nutrition, medical management)

Per patient selection criteria in policy

Eligible procedures: Open or laparoscopic Roux-en-Y gastric bypass; laparoscopic adjustable gastric banding; sleeve gastrectomy (open or laparoscopic); biliopancreatic diversion with duodenal switch (open or laparoscopic)

Procedures listed in policy

Initial bariatric surgery — Class 2 with comorbidity

Covered when ALL of the following are met for adults with Class 2 obesity and one or more comorbidities:

Obesity-related comorbidity: At least one obesity-related comorbid condition (eg, obstructive sleep apnea, type 2 diabetes, hypertension, gastroesophageal reflux disease, nonalcoholic fatty liver disease, severe urinary incontinence, cardiomyopathy, debilitating arthritis)

See patient selection criteria in policy

Failed conservative measures: Failed weight loss by conservative measures (diet, exercise, behavioral changes)

Duration and specifics at surgeon's discretion

Eligible procedures: Laparoscopic or open Roux-en-Y gastric bypass; laparoscopic adjustable gastric banding; sleeve gastrectomy; biliopancreatic diversion with duodenal switch

Procedures listed in policy

Initial bariatric surgery — Class 1 with type 2 diabetes

Covered when ALL of the following are met for adults with Class 1 obesity and type 2 diabetes:

Failed conservative measures: Failed weight loss by conservative measures (diet, exercise, behavioral changes)

Duration and specifics at surgeon's discretion

Eligible procedures: Certain bariatric procedures (eg, Roux-en-Y gastric bypass, sleeve gastrectomy, laparoscopic adjustable gastric banding, biliopancreatic diversion with duodenal switch) as appropriate

Procedures supported by evidence for improvement in T2D outcomes

Revision and repeat surgical procedures

Covered when ANY of the following revision/ repeat conditions are met:

Revision for complications: Revision surgery to address perioperative or late complications of a prior bariatric procedure (eg, staple line failure, band slippage not correctable by adjustment) is medically necessary

Includes revision for severe GERD refractory to medical treatment

Revision for pouch or band dilation: Revision of a primary bariatric procedure for dilation of the gastric pouch or dilation proximal to an adjustable gastric band when initial procedure was successful in inducing weight loss and the individual has been compliant with prescribed nutrition and exercise

Documented by upper GI exam or endoscopy

Repeat surgery for inadequate weight loss or weight regain: Repeat surgical procedures or conversion to another bariatric procedure for inadequate weight loss or weight regain (not due to a surgical complication) are medically necessary

See policy criteria for documentation

Investigational procedures

Not covered / investigational procedures:

Investigational surgical procedures: Procedures considered investigational include vertical-banded gastroplasty; biliopancreatic diversion without duodenal switch (BPD without DS); mini-gastric/one-anastomosis gastric bypass; long-limb gastric bypass (>150 cm); laparoscopic gastric plication; two-stage bariatric procedures; SADI-S; jejunoileal bypass; horizontal gastric partitioning; gastric electrical stimulation for obesity; gastric wrapping

Listed as investigational in policy

Investigational endoscopic procedures and devices: Endoscopic procedures and devices considered investigational include intragastric balloons, endoscopic sleeve gastroplasty, endoscopic gastric suturing (eg, Apollo OverStitch), aspiration therapy devices, BEAM (bariatric endoscopic antral myotomy), endoscopically placed duodenojejunal sleeve, and related CPT/HCPCS codes (eg, 0813T, 43290, 43291, 43645, 43842, 43843, 43847, HCPCS C9784, C9785)

These are considered investigational as primary or revision procedures

Devices explicitly investigational: Specific devices such as the Apollo Device and SADI-s are considered investigational as primary or revision procedures

Bariatric surgery in adolescents

Adolescent criteria:

Weight-based eligibility: Adolescents must meet the same weight-based criteria used for adults (eg, Class 3 BMI or Class 2 BMI with severe comorbidities; selected adolescents with BMI >30 kg/m2 and type 2 diabetes may be eligible)See adult BMI thresholds

Patient Selection Criteria apply (including failed conservative measures and program enrollment)

Device FDA indication: Any devices used for bariatric procedures in adolescents must be consistent with FDA-approved indications

Per policy guidance

Medically Necessary Indications (summary)

Covered when ALL of the following population-specific conditions are met (documented per full policy):

Adults with Class 3 Obesity: Adults (≥18 years) with class 3 obesity (BMI ≥ 40 kg/m2) treated with bariatric surgery (RYGB, LAGB, SG, biliopancreatic diversion with DS) — evidence demonstrates substantial benefit over nonsurgical therapyBMI ≥ 40 kg/m2

See evidence summary

Revision Bariatric Surgery: Revision bariatric surgery for adults has evidence of satisfactory weight loss and reduced comorbidities; revision for GERD is explicitly clarified as an indicationN/A

See revision evidence summary

Investigational / Not Medically Necessary

Not covered / Investigational procedures:

Specific investigational CPT/HCPCS codes: The following CPT codes are considered investigational and not covered: 0813T, 43290, 43291, 43645, 43842, 43843, 43847; and HCPCS codes C9784 and C9785N/A

These codes correspond to intragastric balloons, endoscopic sleeve gastroplasty, certain gastric restrictive procedures and related interventions

Specific investigational procedures and devices: Single Anastomosis Duodenal-ileal switch (SADI-s), one-anastomosis/mini-gastric bypass procedures, and devices such as the Apollo Device and BEAM are considered investigational as primary or revision proceduresN/A

Listed in policy history as investigational

Summary of coverage stance and policy history

Policy history documents changes to medically necessary and investigational indications; specific criteria text appears elsewhere in the full policy.

Medically necessary updates: Medically necessary statement added for bariatric surgery in adults with Class 2 obesity and at least one obesity-related comorbid condition; bariatric surgery in adolescents (ages 12-18) considered medically necessary using similar weight-based criteria to adultsBMI criteria referenced in thresholds

Effective 9/1/2024 and 5/2024

Revision surgery clarification: Medically necessary indications for revision surgery were clarified to include management of GERD and perioperative or late complications of prior bariatric procedures

Clarifications noted in policy history

Bariatric surgery is considered investigational for the treatment of obesity in preadolescent children. This investigational position is explicit in the policy and carried forward in policy history entries describing the investigational status for this age group.

For individuals with BMI < 35 kg/m2 who do not have type 2 diabetes, the evidence is insufficient to determine net health benefit from bariatric surgery. Randomized trials and observational studies show weight loss and some improvements in comorbidities, but available data do not permit conclusions about long‑term risk–benefit for this population.

The policy lists specific devices and procedures as investigational, including the Apollo OverStitch endoscopic gastric suturing system (referenced in the endoscopic procedures list) and surgical procedures such as SADI‑s (Single Anastomosis Duodenal‑ileal switch). These items are explicitly noted as investigational whether used as a primary bariatric procedure or as a revision procedure.

Non‑physician directed elements of multi‑faceted dietary programs, and the food replacement or supplement components of such programs, are considered not medically necessary. Physician‑directed visits and testing aspects may be medically necessary, but components provided without physician direction are excluded.

The policy identifies a list of CPT and HCPCS codes that are considered investigational and not covered for Commercial Members. Examples include investigational CPT codes such as 0813T, 43290, 43291, 43645, 43842, 43843, 43847 and investigational HCPCS codes such as C9784 and C9785. Endoscopic procedures (e.g., intragastric balloons, endoscopic sleeve gastroplasty, endoscopic gastric suturing) are included in this investigational coding list.

Historically, the policy has listed bariatric surgery as investigational for preadolescent children. Prior policy versions and history entries document the investigational designation for this population and related changes over multiple review cycles.

Coding — CPT, HCPCS, and ICD-10 Codes

CPT Codes HCPCS Codes ICD Codes (listed elsewhere in document)mixed

No codes listed

Covered CPT Codes (listed as covered when medical necessity met)CPTCovered

43644	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43770	Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components)
43775	Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)
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)

ICD-10 Procedure CodesICD-10

ODB64Z3	Excision of Stomach, Percutaneous Endoscopic Approach, Vertical
ODB60Z3	Excision of Stomach, Open Approach, Vertical
ODB6OZZ	Excision of Stomach, Open Approach
ODV64CZ	Restriction of Stomach with Extraluminal Device, Percutaneous Endoscopic Approach

ICD-10 Diagnosis Codes considered medically necessary with proceduresICD-10Covered

E66.01	Morbid (severe) obesity due to excess calories
E66.35	Body mass index (BMI) 35.0-35.9, adult
E66.36	Body mass index (BMI) 36.0-36.9, adult
E66.37	Body mass index (BMI) 37.0-37.9, adult
E66.38	Body mass index (BMI) 38.0-38.9, adult
E66.39	Body mass index (BMI) 39.0-39.9, adult
E66.41	Body mass index (BMI) 41.0-41.9, adult
E66.43	Body mass index (BMI) 50.0-59.9, adult
E66.45	Body mass index (BMI) 70 or greater, adult

CPT Codes considered investigationalCPTExperimental

0813T	Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon
43290	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon
43291	Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s)
43645	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
43842	Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
43843	Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
43847	Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption

HCPCS Codes considered investigationalHCPCSExperimental

C9784	Gastric restrictive procedure, endoscopic sleeve gastroplasty, with esophagogastroduodenoscopy and intraluminal tube insertion
C9785	Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion

Coding information (clarified historically)mixed

No codes listed

BMI thresholds referenced in history

Historical Class III wordingReferenced as BMI > 40 kg/m2 or > 35 kg/m2 with comorbidities in policy history updates

Class 2 referenced historicallyPolicy history notes Class 2 obesity as indication for surgery when comorbidity present

Policy revisionsMultiple history entries (effective dates 5/2024, 9/2024, 10/2025) clarify BMI criteria and related indications

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for most bariatric surgical services when performed inpatient and for surgical services in many outpatient products. Failure to obtain required preauthorization may result in denial or reduced coverage. For commercial members, requests must meet medical policy guidelines.

Inpatient services: precertification/preauthorization IS REQUIRED for all products when the procedure is performed inpatient.
Outpatient services: Commercial Managed Care (HMO and POS) — prior authorization is required for surgical services (not required for medical services). Commercial PPO — prior authorization is required for surgical services (not required for medical services).

Prior Authorization

Authorization Manager: how to submit requests

Submit initial authorization requests using Authorization Manager (available 24/7) — this is the preferred and quickest method to review requirements, request authorizations, submit clinical documentation, check case status, and view/print decision letters. For out-of-network providers, fax requests to 888-282-0780.

Enter the servicing surgeon's NPI or provider ID (not the billing group).

Background and Definitions

Obesity is stratified by body mass index (BMI) and associated with multiple weight‑related complications (for example, type 2 diabetes, obstructive sleep apnea, dyslipidemia, hypertension, nonalcoholic fatty liver disease, and osteoarthritis). Bariatric surgery is intended to reduce gastric capacity and/or absorption to promote weight loss and improve these comorbid conditions and is considered for appropriately selected patients who have failed conservative measures.

Weight-related complications (examples)

Type 2 diabetesListed as a weight-related complication and a qualifying comorbidity for lower BMI thresholds (Class 1 eligibility)

Obstructive sleep apnea (OSA)Included among weight-related complications that may qualify a patient with lower BMI for surgery

Dyslipidemia, Hypertension, NAFLD, OsteoarthritisExamples of obesity-related comorbid conditions cited as qualifying complications

Patient selection criteria for adults

OpenPayer

Bariatric Surgery and Related Obesity Management Services

Coverage Criteria for Bariatric Surgery and Related Procedures

Coding — CPT, HCPCS, and ICD-10 Codes

Provider Requirements, Prior Authorization, and Documentation

Background and Definitions