CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Bariatric Surgery — Procedures Not Covered / Not Medically Necessary

Defines bariatric surgery procedures that BCBSRI considers not covered for Medicare Advantage Plans and not medically necessary for Commercial Products, and provides coding guidance and background for these determinations.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyBariatric Surgery — Procedures Not Covered / Not Medically Necessary

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateJun 1, 2023

Next Review DateN/A

Key ActionFile claims for procedures without specific CPT codes using the listed unlisted stomach procedure codes (e.g., 43999 or 43659) and verify benefits against the member's Evidence of Coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3CPT codes listed as not covered / not medically necessary

≥15Distinct procedures/devices listed

3Unlisted CPT codes recommended

1HCPCS not reimbursed

NIH thresholdsBMI criteria referenced

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Coverage determinations

Medicare Advantage - Not Covered

The procedures listed are considered not covered for Medicare Advantage Plans:

Medicare Advantage not covered procedures: Open adjustable gastric banding; Open sleeve gastrectomy; Gastric balloon for treatment of obesity; Open and laparoscopic vertical banding gastroplasty; Intestinal bypass

Listed explicitly as not covered for Medicare Advantage Plans

Commercial Products - Not Medically Necessary

The procedures listed are considered not medically necessary for Commercial Products:

Commercial not medically necessary procedures: Gastric bypass using Billroth II type of anastomosis (mini-gastric bypass); Vertical-banded gastroplasty; Biliopancreatic bypass without duodenal switch; Two-stage bariatric surgery procedures (e.g., sleeve gastrectomy followed by biliopancreatic diversion); Long-limb gastric bypass (>150 cm); Laparoscopic gastric plication; Single anastomosis duodeno-ileal bypass with sleeve gastrectomy; Insertion of the StomaphyX device; Endoscopic gastroplasty; Endoscopically placed duodenojejunal sleeve; Intragastric balloons; Aspiration therapy device

Listed explicitly as not medically necessary for Commercial Products

Investigational / Insufficient Evidence

Investigational / insufficient evidence statements

Procedures considered investigational: Endoscopic procedures for revisional treatment of weight regain after bariatric surgery (including use of suturing devices, sclerosing injections, and devices such as StomaphyX) due to limited published data and absence of comparative trials; Bariatric surgery in patients with BMI < 35 kg/m2; Bariatric surgery in preadolescent children

Stated lack of adequate comparative trials or guideline support; evidence base considered insufficient to determine effects on health outcomes

Benefits for bariatric surgery and related services may vary between groups and contracts. Refer to the member's specific Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether a particular procedure or indication is covered under the applicable plan.

The following CPT codes are identified in this policy as not covered for Medicare Advantage Plans and not medically necessary for Commercial Products: 43290 (Esophagogastroduodenoscopy with deployment of intragastric bariatric balloon), 43843 (Gastric restrictive procedure, without gastric bypass, other than vertical-banded gastroplasty), and procedures for vertical-banded gastroplasty.

HCPCS code S2083 (adjustment of band diameter via subcutaneous port by injection or aspiration of saline) is not separately reimbursed under this policy.

The following bariatric and endoscopic procedures are designated not medically necessary for treatment of morbid obesity in adults who have failed conservative measures due to insufficient evidence of benefit: gastric bypass using a Billroth II type anastomosis (mini-gastric bypass); vertical-banded gastroplasty; biliopancreatic bypass without duodenal switch; two-stage bariatric procedures (e.g., sleeve gastrectomy followed later by biliopancreatic diversion); long-limb gastric bypass (>150 cm); laparoscopic gastric plication; and single anastomosis duodeno-ileal bypass with sleeve gastrectomy.

Endoscopic procedures that are considered not medically necessary as either primary bariatric procedures or as revision procedures include insertion of the StomaphyX device, endoscopic gastroplasty, use of an endoscopically placed duodenojejunal sleeve, intragastric balloons, and aspiration therapy devices; published data are limited and comparative trials are lacking to support these approaches.

Procedures represented by CPT codes 43290 and 43843, as well as vertical-banded gastroplasty, are explicitly listed in this policy as not covered for Medicare Advantage Plans and not medically necessary for Commercial Products for the indicated bariatric uses.

Coding guidance

Not covered / not medically necessary CPT codesCPTNot Covered

43290	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon (New code 1/01/2023)
43843	Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
43844	Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty

Unlisted CPT codes for claimsCPT

43999	Unlisted procedure, stomach
43659	Unlisted laparoscopy procedure; stomach

HCPCS not separately reimbursedHCPCSNot Covered

S2083

Adjustment of band diameter via subcutaneous port by injection Or aspiration Of saline

Not covered / Not medically necessary CPT codesCPTNot Covered

43290	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon (New code 1/01/2023)
43843	Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
unlisted (vertical-banded gastroplasty)	Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty

Unlisted CPT codes for claims filing when specific codes are not availableCPT

43999	Unlisted procedure, stomach
43659	Unlisted laparoscopy procedure; stomach

HCPCS code not separately reimbursedHCPCSNot Covered

S2083

Adjustment of band diameter via subcutaneous port by injection Or aspiration Of saline gastric

BMI — thresholds used to define morbid obesity

BMI threshold — morbid obesity> 40 kg/m2

BMI threshold — morbid obesity with comorbidities> 35 kg/m2 with associated complications (e.g., diabetes, hypertension, obstructive sleep apnea, coronary artery disease)

NIH consensus reference for surgical candidacy1991 NIH Consensus: candidates defined as BMI >40 kg/m2 or >35 kg/m2 with severe comorbidities

What providers should do / billing and authorization

Prior Authorization

Prior authorization applicability

Prior authorization is NOT applicable to determinations of services that are considered not covered (Medicare Advantage) or not medically necessary (Commercial) under this policy. For all other bariatric surgery services, providers should refer to the payer's Prior Authorization via Web-Based Tool for Procedures policy.

Prior Authorization

Prior authorization guidance

For related prior authorization requirements (for services not addressed as not covered/not medically necessary here), providers must use Blue Cross Blue Shield - Rhode Island's Prior Authorization via Web-Based Tool for Procedures. This policy does not replace that web-based prior authorization process.

Clinical background

Bariatric surgery is performed to treat morbid (clinically severe) obesity in patients who have not achieved adequate weight loss with conservative measures. Morbid obesity is defined as a body mass index (BMI) of > 40 kg/m2 or a BMI of > 35 kg/m2 with associated comorbid conditions (for example, diabetes, hypertension, obstructive sleep apnea, or coronary artery disease). Surgical techniques produce weight loss through restrictive, malabsorptive, or combined mechanisms, and the quality and duration of evidence vary across procedures; comparative long-term randomized data are limited for multiple newer or variant techniques.

Terms and variants

Definition of morbid obesity

Definition — morbid obesityBMI >40 kg/m2 or BMI >35 kg/m2 with associated complications (including, but not limited to, diabetes, hypertension, obstructive sleep apnea, coronary artery disease)

Clinical note — first-line treatmentInitial treatment is dietary and lifestyle changes; surgery considered when conservative measures fail

Rationale — riskMorbid obesity results in very high risk for weight-related complications and shortened life span

Definitions of gastric bypass variants

Mini-gastric bypass (Billroth II type anastomosis)Stomach is anastomosed directly to jejunum (Billroth II–type) rather than a Roux-en-Y; distinguishing feature is type of anastomosis

Long-limb Roux-en-Y gastric bypass (>150 cm)

Policy revision timeline

2023-04provider_updateLatest

Provider Update published (April 2023).

2022-05provider_update

Provider Update published (May 2022).

2021-06provider_update

Provider Update published (June 2021).