Medical Coverage Policy Bariatric Surgery
Defines BCBS Rhode Island coverage stance for various bariatric surgical and endoscopic procedures for Medicare Advantage and Commercial products, listing procedures considered not covered or not medically necessary and providing background, coding guidance, and references.
No material changes to clinical coverage or policy were identified.
Coverage Summary
This policy defines Blue Cross & Blue Shield of Rhode Island (BCBSRI) coverage stance for bariatric surgical and endoscopic procedures for Medicare Advantage and Commercial products. For Medicare Advantage, BCBSRI follows CMS national/local coverage determinations and lists certain procedures (e.g., open adjustable gastric banding, open and laparoscopic vertical banding gastroplasty, open sleeve gastrectomy, gastric balloon, intestinal bypass) as not covered. For Commercial products, several procedures are listed as not medically necessary (e.g., vertical-banded gastroplasty, mini-gastric bypass, long-limb gastric bypass >150 cm, biliopancreatic bypass without duodenal switch, two-stage procedures, laparoscopic gastric plication, single anastomosis duodenoileal bypass with sleeve gastrectomy) and select endoscopic procedures (e.g., StomaphyX device, endoscopic gastroplasty, intragastric balloons, endoscopically placed duodenojejunal sleeve, aspiration therapy) are considered not medically necessary/investigational. Morbid obesity is defined as BMI > 40 kg/m2 or BMI > 35 kg/m2 with associated complications. Policy effective date: 04/21/2021; last review: 03/02/2022.
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