CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Bariatric Surgery

Defines medical necessity criteria, covered and not-covered bariatric surgical procedures for BlueCHiP for Medicare and Commercial products, prior authorization requirements, applicable CPT codes, and coverage limits/exclusions.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Bariatric Surgery

Policy CodePolicy N/A

Change TypeClarified (provider updates listed; no material clinical changes)

Effective DateNov 4, 2014

Next Review Date

Key ActionPrior authorization is required for BlueCHiP for Medicare and recommended for Commercial products via the online web-based tool for participating providers.

SourceLink

POLICY UPDATE CHANGES

Policy last updated 07/17/2018; published provider updates listed (2015-2018).

12Listed Covered or Potentially Covered CPTs

10Listed Not Covered / Not Medically Necessary Procedures

2Unlisted CPTs to use for excluded indications

Coverage Summary

Overview: This policy defines medical necessity criteria for bariatric surgery for morbid obesity. Status: CURRENT. Subject: Bariatric Surgery. Effective date: 2014-11-04; Last review: 2018-07-17. Scope: defines covered and not-covered bariatric surgical procedures, prior authorization requirements, applicable CPT codes, and coverage limits/exclusions. NIH guidance: a 1991 NIH Consensus defined surgical candidates as those with BMI >40 kg/m2 or BMI >35 kg/m2 with severe comorbidities. Evidence/background: evidence varies by procedure; some endoscopic and novel procedures lack sufficient evidence and are considered investigational. Coverage stance: mixed (some procedures covered when criteria met; others considered not covered or investigational).

Medical-Necessity Criteria

General Medical Criteria for Bariatric Surgery

Bariatric surgery is covered when the following criteria are met:

ALL of the following

Patient has morbid obesity
Failure to lose weight with conservative measures (medical treatment/dietary and lifestyle changes)

BlueCHiP for Medicare Specific Criteria

Either

Body mass index (BMI) >= 35
Have at least one comorbidity related to obesity and have been previously unsuccessful with medical treatment for obesity

Commercial Products Prior Authorization Requirement

ALL of the following

Prior authorization for covered services may be obtained via the online tool for participating providers (recommended)

Codes and Billing

Covered CPT codes (when medical criteria met)CPTCovered

43644	Laparoscopy, surgical, restrictive procedure; with bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43645	Laparoscopy, surgical, restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
43771	Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only
43770	Laparoscopy, surgical, restrictive procedure; placement of adjustable restrictive device (band and subcutaneous port components)
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, restrictive procedure; removal of adjustable restrictive device and subcutaneous components
43775	Laparoscopy, surgical, restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy)
43845	Gastric restrictive procedure with gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) (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

1–10 of 12

1/2

Not separately reimbursedHCPCS|CPTNot Covered

S2083

Adjustment of gastric band diameter via subcutaneous injection or aspiration of saline port (not separately reimbursed)

Not covered / Not medically necessary CPT codesCPTNot Covered

43842

Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty (BlueCHiP for Medicare: not covered; Commercial: not medically necessary)

Unlisted procedure codes for not covered/ not medically necessary indicationsCPTNot Covered

43999	Unlisted procedure, stomach (use for not covered indications listed in policy)
43659	Unlisted laparoscopy procedure, stomach (use for not covered indications listed in policy)

Provider Actions & Billing Rules

Prior Authorization

Prior authorization requirement

Prior authorization is required for BlueCHiP for Medicare and is recommended for Commercial products. Participating providers may obtain prior authorization via the online web-based tool.

Documentation Required

Demonstrate failure of conservative treatment

Providers must document prior unsuccessful medical treatment, including dietary and lifestyle measures, prior to bariatric surgery.

Billing Rule

Use unlisted codes for excluded procedures

For the procedures listed in this policy that are not covered or not medically necessary and lack specific CPT codes, file claims using unlisted procedure codes.

43659
43999

Billing Rule

Do not separately reimburse band adjustment

Code S2083 (adjustment of gastric band diameter via subcutaneous injection or aspiration of saline port) is not separately reimbursed.

S2083

Background & Evidence

Background summary: Bariatric surgery is a treatment for morbid (clinically severe) obesity when conservative measures (dietary and lifestyle changes and medical management) fail. Numerous surgical techniques exist with heterogeneous mechanisms (restriction, malabsorption, metabolic changes). A 1991 NIH Consensus Conference defined surgical candidates as patients with BMI >40 kg/m2 or BMI >35 kg/m2 with severe comorbidities (for example cardiopulmonary complications or severe diabetes).

Indications and coverage: Specific procedures (e.g., Roux-en-Y gastric bypass, biliopancreatic diversion with duodenal switch, laparoscopic adjustable gastric banding, sleeve gastrectomy) are listed as medically necessary when the policy medical criteria are met; BlueCHiP for Medicare and Commercial product rules and prior authorization requirements apply. Some open procedures and procedure variants (for example open sleeve gastrectomy, open adjustable gastric banding, vertical-banded gastroplasty, certain long-limb or alternative bypass techniques) are listed as not covered or not medically necessary depending on product.

Investigational procedures: Evidence is insufficient for a number of endoscopic and novel procedures (for example intragastric balloons, endoscopic gastroplasty, StomaphyX device, endoscopically placed duodenojejunal sleeves, aspiration therapy, and other endoscopic revision devices); these endoscopic procedures are considered investigational.

Source	Key Point
NIH Consensus (as cited in policy background)	Candidates: BMI >40 or BMI >35 with severe comorbidities
Policy source: Medical Coverage Policy Bariatric Surgery	Candidates: BMI >40 or BMI >35 with severe comorbidities

Definitions: Morbid obesity — clinically severe obesity with significant weight-related complications (for example diabetes, hypertension, obstructive sleep apnea, coronary artery disease) that are not controlled by best-practice medical management and that result in very high risk for weight-related complications and shortened life span.