Bariatric Surgery — SADI-S and Related Procedures
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Governs coverage and medical necessity for single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) and states procedures and endoscopic techniques that are not covered or not medically necessary for Medicare Advantage and Commercial products.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity
SADI-S Medical Necessity
SADI-S may be considered medically necessary when ALL of the following are met:
Preadolescents (<13 years) are not covered
For adolescents, give greater consideration to psychosocial and informed consent issues
Revision Surgery — Medically Necessary Indications
Revision surgery to address perioperative or late complications is considered medically necessary when specific conditions are met:
These examples are not exhaustive
Coverage determinations by procedure category
Coverage stance varies by procedure based on available evidence; many procedures are considered investigational/insufficient evidence
see evidence summary
Medicare Advantage exclusions
Medicare Advantage-specific noncoverage per CMS NCDs/LCDs
Applies to Medicare Advantage Plans only
The policy lists multiple bariatric and endoscopic procedures that are considered not covered for Medicare Advantage Plans or not medically necessary for Commercial Products because the available evidence is insufficient to determine effects on health outcomes. Examples include open adjustable gastric banding, open sleeve gastrectomy, open and laparoscopic vertical banding gastroplasty, gastric balloon for treatment of obesity, and intestinal bypass. Commercial Products also list additional procedures and endoscopic techniques as not medically necessary, reflecting differences between Medicare Advantage and Commercial benefit determinations.
Providers should note that Medicare Advantage determinations follow applicable CMS national and local coverage determinations and therefore may differ from Commercial product coverage; in some cases Medicare Advantage coverage may be more restrictive per CMS guidance.
Specific procedures and CPT/HCPCS codes identified as not covered for Medicare Advantage or not medically necessary for Commercial Products are listed in the coding section. Not-covered / not medically necessary CPT codes include 43290, 43842, 43843, and 0813T. The HCPCS code S2083 is noted as not separately reimbursed.
Separate lists of procedures considered not covered for Medicare Advantage Plans include open adjustable gastric banding, open sleeve gastrectomy, open and laparoscopic vertical banding gastroplasty, gastric balloon for treatment of obesity, and intestinal bypass. For Commercial Products, not medically necessary procedures include vertical-banded gastroplasty, Billroth II type gastric bypass (mini-gastric bypass), biliopancreatic bypass without duodenal switch, and long-limb gastric bypass (>150 cm).
SADI-S (single anastomosis duodeno-ileal bypass with sleeve gastrectomy) is considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products when the policy's specified medical criteria are not met. The policy requires documented attainment of the listed medical criteria for the procedure to be considered medically necessary.
Because SADI-S has no specific CPT code, billing typically uses unlisted CPT codes; providers should ensure documentation demonstrates the patient meets all medical necessity requirements before submitting claims.
When used to perform a long-limb gastric bypass with Roux limb length greater than 150 cm, CPT code 43847 is considered not medically necessary for Commercial Products. This exclusion is specific to long-limb gastric bypass procedures and applies when the surgical limb length exceeds the stated >150 cm cutoff.
Coding and Billing Guidance
| 43847 | Gastric restrictive procedure with gastric bypass; with small intestine reconstruction to limit absorption |
| 43846 | Roux-en-Y gastroenterostomy (gastric bypass) — short limb (<150 cm) described in policy text |
| 43843 | Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty (used for gastric plication) |
| 43659 | Unlisted laparoscopy procedure, stomach |
| 43999 | Unlisted procedure, stomach |
| 44799 | Unlisted procedure, small intestine |
| 44238 | Unlisted laparoscopy procedure, intestine (except rectum) |
| 43848 | Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) |
| 43290 | Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon |
| 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 |
| 0813T | Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon (New code 1/01/2024) |
| S2083 | Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline |
| 43847 | Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption |
Provider Responsibilities and Billing Notices
Prior authorization required (Medicare Advantage); recommended (Commercial)
Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products for Single Anastomosis Duodeno-ileal Bypass with Sleeve Gastrectomy (SADI-S). Prior authorization is also required for CPT code 43847 for Medicare Advantage Plans and recommended for Commercial Products.
- Obtain prior authorization before scheduling SADI-S for Medicare Advantage members.
- Recommendation to obtain prior authorization for Commercial Product members to confirm coverage and requirements.
Use unlisted CPTs for SADI-S; non-covered CPTs may be denied
SADI-S has no specific CPT code; use one of the listed unlisted CPT codes when filing claims. Claims for certain specified CPTs (e.g., intragastric balloon deployment and some gastric restrictive procedure codes) are not covered or not medically necessary and may be denied if billed.
Prior authorization procedural list — none specified here
This excerpt does not list a procedure-specific prior authorization code list beyond the statements that prior authorization is required for Medicare Advantage and recommended for Commercial Products.
- Refer to related Prior Authorization policies for procedure-level authorization rules.
- Confirm code-specific authorization requirements with the payer when filing.
Policy scope — SADI-S and Medicare Advantage/Commercial coverage
The policy specifically addresses SADI-S for Medicare Advantage Plans and Commercial Products and also identifies services that are not covered for Medicare Advantage Plans and not medically necessary for Commercial Products.
- This policy governs coverage and medical necessity decisions for SADI-S and lists procedures/services excluded for Medicare Advantage and/or Commercial Products.
No step therapy specified
No step therapy requirements are specified in this portion of the policy.
- Follow the related Prior Authorization policy for any applicable step therapy rules not covered here.
Document preoperative EGD findings and rationale
Document that preoperative esophagogastroduodenoscopy (EGD) was considered and any findings that could alter operative management; systematic reviews report only about one-fifth of EGDs change operative plans, so documentation should justify EGD use for the individual patient.
- Record indications for EGD and any findings that influenced surgical planning (e.g., malignancy, large hiatal hernia, peptic ulcer, H. pylori).
- If EGD was not performed, document rationale based on individualized assessment.
Verify eligibility and benefits with payer
Verify member-specific benefits and eligibility by contacting the provider call center; coverage is governed by the member's subscriber agreement or employer agreement.
- Confirm benefit coverage, prior authorization requirements, and any member cost-sharing before scheduling.
- Refer to the subscriber certificate and employer agreement for definitive coverage determinations.
Coverage denial risk when medical criteria are not met
SADI-S is considered not covered for Medicare Advantage Plans and is not medically necessary for Commercial Products when the policy medical criteria are not met.
- Do not perform or bill SADI-S when a patient fails to meet the listed medical criteria; such services may be denied.
SADI-S not covered for preadolescents (<13 years)
SADI-S for preadolescent individuals (< age 13) is considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products.
- Do not perform or bill SADI-S for patients younger than 13; such claims are noncovered and may be denied.
Non-covered / not medically necessary CPT codes — risk of denial
Claims for the specified intragastric balloon CPTs and certain gastric restrictive procedure CPTs are listed as not covered or not medically necessary and may be denied if billed.
Denial risk and member charge restrictions
Services determined to be not medically necessary or non-covered benefits may not be paid; providers may not charge members for these services unless the member was informed and agreed in writing in advance.
- Obtain a written advance agreement from the member if they elect to proceed with non-covered services to avoid billing disputes.
- Confirm coverage and obtain necessary prior authorization to reduce risk of unpaid claims.
Clinical Background
Bariatric surgery is a recognized treatment option for morbid obesity when conservative measures have failed. These surgical procedures employ a variety of mechanisms to produce weight loss, including gastric restriction, creation of malabsorptive intestinal bypasses, and metabolic effects from alteration of gastrointestinal anatomy.
Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) combines a sleeve gastrectomy with an intestinal bypass anastomosis; it has been proposed as an alternative to Roux-en-Y gastric bypass and randomized evidence cited in the policy demonstrates greater weight loss at 2 years compared with RYGB in the reported trial, with a similar safety profile.
Definitions and Procedure Terms
Policy Revision History
Policy effective date for SADI-S coverage criteria and coding guidance including recommended unlisted CPTs for SADI-S and identification of specific CPTs not covered/not medically necessary.
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