CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

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.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Bariatric Surgery

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 21, 2021

Next Review Date

Key ActionFile claims for procedures without specific CPT codes using the appropriate unlisted CPT codes (43999 or 43659); refer to member benefit documents for contract-specific coverage and note that Medicare Advantage determinations follow CMS NCDs/LCDs.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or policy were identified.

MultipleProcedures listed as not covered / not medically necessary

BMI >35 or >40BMI thresholds referenced

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.

Display thresholds and high-level stats

BMI for morbid obesityBMI > 40 kg/m2 or BMI > 35 kg/m2 with associated comorbidities

Procedures listed as not covered / not medically necessaryMultiple (see list: open adjustable gastric banding; vertical banding gastroplasty; open sleeve gastrectomy; gastric balloon; intestinal bypass; various others and endoscopic procedures)

Endoscopic devices considered investigationalIntragastric balloons and certain endoscopic suturing/devices (e.g., StomaphyX, endoscopic gastroplasty) are considered investigational/not medically necessary

Codes referenced for not covered/not medically necessary43290, 43842, and use of unlisted codes 43999/43659 for procedures without specific CPT codes

Medical Necessity / Not Medically Necessary Criteria

Bariatric Surgery for BMI < 35 kg/m2

Coverage stance for individuals with BMI less than 35 kg/m2:

Bariatric surgery for BMI < 35 kg/m2: Bariatric surgery for patients with BMI < 35 kg/m2 is considered investigational and not standard of care (including for patients without diabetes).BMI < 35 kg/m2

Limited evidence for improved health outcomes; not supported by specialty society guidelines.

Bariatric Surgery in Preadolescent Children

Coverage stance for preadolescent children:

Bariatric surgery in preadolescent children with morbid obesity is considered investigational due to insufficient evidence and guideline recommendations against performing bariatric surgery in preadolescents.preadolescent age group

No studies focused on this population; guidelines recommend against.

Coding

Not Covered / Not Medically Necessary Procedure CodesCPTNot Covered

43290	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon (New code 1/01/2023)
43842	Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty

Unlisted Codes for Not Covered / Not Medically Necessary IndicationsCPTNot Covered

43999	Unlisted procedure, stomach
43659	Unlisted laparoscopy procedure, stomach

Adjustment of Band DiameterHCPCS

S2083

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

Provider Actions & Billing Guidance

Billing Rule

Use of Unlisted CPT for Non-Covered Procedures

Claims for procedures listed as not covered or not medically necessary that have no specific CPT code should be filed using the appropriate unlisted CPT codes.

43999
43659

Denial Risk

Coverage Determination for Medicare Advantage

For Medicare Advantage members, BCBSRI follows CMS national and local coverage determinations; procedures listed as not covered for Medicare Advantage will be denied per CMS guidance.

Documentation Required

Refer to Benefit Booklet / Evidence of Coverage

Benefits and coverage vary by contract. Providers must refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable surgery benefits and coverage determinations.

Background & Evidence

Morbid obesity is defined as BMI > 40 kg/m2 or BMI > 35 kg/m2 with associated complications (for example, diabetes, hypertension, obstructive sleep apnea). The evidence is sufficient to support some established bariatric procedures: systematic reviews and comparative data support gastric bypass and indicate that sleeve gastrectomy has similar or lower short-term complications with medium- to long-term weight loss, though weight loss may be somewhat less than bypass. The evidence is insufficient to determine the effects on health outcomes for many other procedures (including long-limb gastric bypass variants, biliopancreatic bypass without duodenal switch, single-anastomosis duodenoileal bypass with sleeve gastrectomy, and other novel surgical approaches). Endoscopic bariatric devices and procedures have limited and low-quality evidence; intragastric balloons are described as unproven/insufficient evidence with reported adverse effects (e.g., gastric erosion, reflux, obstruction), and endoscopic suturing or pouch-reduction devices (e.g., StomaphyX, endoscopic gastroplasty) are considered investigational due to very limited published data and lack of comparative trials.

Source	Summary
CMS NCD referenced	NCD for Bariatric Surgery (100.1) cited in policy and references; BCBSRI follows CMS NCDs/LCDs for Medicare Advantage plans
Literature	Multiple systematic reviews and randomized trials/meta-analyses cited (e.g., JAMA, Cochrane, BMJ; specific citations include Buchwald et al. JAMA 2004; Courcoulas et al. JAMA 2013; Cochrane review 2014; BMJ 2013; other meta-analyses and RCTs on gastric bypass, sleeve gastrectomy, adjustable gastric banding), summarized as sufficient evidence for some procedures (gastric bypass, sleeve gastrectomy) and insufficient for many others/endoscopic devices

Source

Summary

CMS NCD referenced

NCD for Bariatric Surgery (100.1) cited in policy and references; BCBSRI follows CMS NCDs/LCDs for Medicare Advantage plans

Literature

Multiple systematic reviews and randomized trials/meta-analyses cited (e.g., JAMA, Cochrane, BMJ; specific citations include Buchwald et al. JAMA 2004; Courcoulas et al. JAMA 2013; Cochrane review 2014; BMJ 2013; other meta-analyses and RCTs on gastric bypass, sleeve gastrectomy, adjustable gastric banding), summarized as sufficient evidence for some procedures (gastric bypass, sleeve gastrectomy) and insufficient for many others/endoscopic devices

Number	Name	Type	Effective Date
100.1	Bariatric Surgery For Treatment Of Co-Morbid Conditions Related To Morbid Obesity	NCD