CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Bariatric Surgery

Defines BCBSRI coverage stance for various bariatric and endoscopic obesity procedures for Medicare Advantage and Commercial products, including which procedures are considered not covered or not medically necessary.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyBariatric Surgery (Clinical/Medical Policy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 21, 2021

Next Review DateN/A

Key ActionVerify member benefits and eligibility per the Benefit Booklet and submit claims using listed or unlisted CPT codes as directed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=1procedures not covered / not medically necessary

BMI>40 or BMI>35NIH surgical candidacy cited

InvestigationalEndoscopic procedures stance

InvestigationalBariatric surgery for BMI <35

43842, 43659, 43999Codes referenced

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Investigational / Insufficient Evidence

The following procedures and indications are considered investigational or have insufficient evidence to determine the effects on health outcomes and are therefore not covered.

ANY of the following

Endoscopic procedures as primary bariatric procedures or as revision procedures (e.g., to treat weight regain after bariatric surgery or to remedy enlarged gastric stoma or gastric pouches), including but not limited to insertion of the StomaphyX device, endoscopic gastroplasty, intragastric balloons, endoscopically placed duodenojejunal sleeves, and aspiration therapy devices.
Published data are limited to small case series and feasibility studies; no comparative trials identified; considered investigational.
Single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S).
No controlled trials identified; evidence limited to case series with short- to mid-term follow-up; considered investigational/insufficient evidence.
Laparoscopic gastric plication (laparoscopic greater curvature or anterior gastric plication).
Technique not standardized; evidence limited; considered investigational/insufficient evidence.
Biliopancreatic bypass without duodenal switch and other less common bypass variants (e.g., mini-gastric bypass / Billroth II type anastomosis, long-limb gastric bypass >150 cm).
Insufficient evidence to form conclusions on long-term health outcomes; higher risk of nutritional complications reported for some procedures; considered investigational/insufficient evidence.

Bariatric Surgery in Preadolescent Children

Bariatric surgery in preadolescent children is considered investigational.

ALL of the following

Patients who are preadolescent children (generally <12 years of age).
No evidence demonstrating improved health outcomes for this specific population; available studies in adolescents include few or no separately reported preadolescent subjects.
Clinical practice guidelines recommend against performing bariatric surgery in preadolescent children.
Therefore, bariatric surgery in preadolescent children is considered investigational due to insufficient evidence on survival, disease status, functional outcomes, quality of life, and treatment-related morbidity and mortality.

Other Procedure Types (e.g., Biliopancreatic Bypass)

Other specific procedure types for which the evidence is insufficient to determine net health benefit and are considered investigational/ not medically necessary include the following.

ANY of the following

Biliopancreatic bypass without duodenal switch.
Weight loss may be similar or greater than other bypass procedures but complication and nutritional deficiency rates may be higher; evidence base insufficient to conclude net health benefit.
Mini-gastric bypass (gastric bypass with a Billroth II type anastomosis).
Limited comparative evidence; considered investigational/insufficient evidence.
Long-limb gastric bypass procedures (e.g., limb length >150 cm).
Insufficient evidence on long-term outcomes and potential increased complications; considered investigational/insufficient evidence.
Two-stage bariatric surgery approaches where an initial procedure (e.g., sleeve gastrectomy) is routinely followed by biliopancreatic diversion at a later time for primary obesity treatment, and other uncommon/novel bypass variants (e.g., single anastomosis duodenoileal bypass with sleeve gastrectomy).

Coding and Billing References

Referenced CPT/HCPCS and unlisted codesmixed

S2083	Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline
43842	Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty (not separately reimbursed)
43999	Unlisted procedure, stomach
43659	Unlisted laparoscopy procedure, stomach

Covered/Referenced bariatric procedure CPT codesCPT

43846	Gastric restrictive procedure with Roux-en-Y gastroenterostomy (short limb) — CPT explicitly describes Roux-en-Y and not applicable to mini-gastric or long-limb variants
43847	Gastric restrictive procedure with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption

Referenced procedure and unlisted codesCPT

S2083	Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline
43842	Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty (not separately reimbursed)
43999	Unlisted procedure, stomach (to be used for indications listed as not covered/not medically necessary)
43659	Unlisted laparoscopy procedure, stomach

inv-13: BMI — NIH surgical candidacy definition (surgical candidacy)

NIH surgical candidacyPatients with BMI > 40 kg/m2, or BMI > 35 kg/m2 with severe comorbidities (e.g., cardiopulmonary complications, severe diabetes)

Definition source1991 NIH Consensus Conference definition cited in policy background

Associated complications examplesDiabetes, hypertension, obstructive sleep apnea, coronary artery disease

inv-14: BMI threshold — reference to < 35 kg/m2 as investigational cutoff

Investigational cutoffBariatric surgery for patients with BMI < 35 kg/m2 is considered investigational

Evidence summaryLimited evidence for BMI < 35 kg/m2; case series report diabetes remission but not supported by specialty guidelines

Coverage stanceNot standard of care; investigational for diabetes and non-diabetes indications in this BMI group

Prior Authorization, Billing, and Provider Responsibilities

Note

Benefit verification

Verify member benefits and eligibility before scheduling services. Refer to the member's Benefit Booklet / Evidence of Coverage / Subscriber Agreement for specific surgery benefits, coverage details, and any contract limitations.

Refer to Benefit Booklet / Evidence of Coverage / Subscriber Agreement for surgery benefits and coverage.

Prior Authorization

Prior authorization required

Prior authorization is required for applicable bariatric procedures. Use the payer's web-based prior authorization tool for procedures as indicated by Blue Cross & Blue Shield - Rhode Island.

Use BCBSRI web-based prior authorization tool for procedures.
Check the payer portal for procedure-specific authorization requirements.

Prior Authorization

Prior authorization and claim submission

Prior authorization and claim submission must be completed per contract and payer instructions. Submit claims using applicable CPT codes or the appropriate unlisted CPT when no specific code exists (e.g., 43999, 43659).

Submit claims using specific CPTs when available; otherwise use Unlisted Procedure codes 43999 or 43659 as appropriate.
Verify if prior authorization was obtained before filing claims.

Denial Risk

Denial risk for listed procedures

Some listed procedures and codes are not covered or are considered not medically necessary and will be denied if billed. Confirm coverage before performing these procedures.

Procedures listed as not covered/not medically necessary will be denied if billed.
For Medicare Advantage Plans, follow CMS national/local coverage determinations which may differ from Commercial products.

Denial Risk

Coding-based denial risks

Certain CPT codes are not separately reimbursed or are explicitly not covered and may result in coding-based denials. Review coding guidance prior to claim submission.

43842 — not separately reimbursed (vertical-banded gastroplasty).
S2083 — code listed (adjustment of gastric band diameter) and may have specific reimbursement rules.

Note

Conservative therapy first

Conservative (non-surgical) management is first-line for morbid obesity. Bariatric surgery is considered only after adequate dietary, lifestyle, and medical management have failed.

Require documentation of failed conservative measures (dietary and lifestyle interventions) prior to surgical consideration.
Ensure records show attempts at weight-loss through best-practice medical management before proceeding.

Documentation Required

Member eligibility and billing notice

Providers must verify member-specific benefits and notify members if services are denied or not covered. If a non-covered service will be provided, obtain the member's written agreement before billing the member.

Call the provider call center for member-specific benefit and eligibility information.
If services are determined not medically necessary or non-covered, inform the member and obtain written agreement before charging them.

Definitions and Terminology

inv-24: Morbid obesity — BMI definitions

Morbid obesity definitionBMI > 40 kg/m2, or BMI > 35 kg/m2 with associated complications (e.g., diabetes, hypertension, obstructive sleep apnea)

Clinical significanceMorbid obesity confers very high risk for weight-related complications and shortened life expectancy

First-line therapyDietary and lifestyle changes are the first treatment; surgery considered when conservative measures fail

inv-25: Mini-gastric bypass / long-limb gastric bypass — procedural variants

Mini-gastric bypass definitionVariant of gastric bypass using a Billroth II–type anastomosis (jejunum anastomosed directly to stomach) rather than a Roux-en-Y

Long-limb gastric bypass definitionRoux-en-Y variations with alimentary/common limb lengths altered (eg, limb >150 cm) combining restriction with malabsorption

Coding noteCPT code 43846 explicitly describes a Roux-en-Y (short-limb) and would not apply to mini-gastric bypass; long-limb variants differ from CPT 43846 description

inv-26: BMI < 35 kg/m2 — definition and investigational status

DefinitionPatients with body mass index under 35 kg/m2

Investigational statusBariatric surgery for BMI < 35 kg/m2 is considered investigational due to limited evidence and lack of specialty society guideline support

Diabetes-specific noteCase series report diabetes remission after gastric bypass in BMI < 35 kg/m2, but this is not currently standard of care

inv-27: Preadolescent children — age definition and coverage rationale

Preadolescent age definitionChildren younger than 12 years old

Evidence rationaleEvidence is insufficient to determine effects of bariatric surgery in preadolescent children; studies did not report outcomes separately for this group

Guideline recommendationClinical practice guidelines recommend against performing bariatric surgery in preadolescent children

Revision History

2021-06Provider UpdateLatest

Provider Update published in June 2021 referencing policy developments and provider communications.

2020-09Provider Update

Provider Update published in September 2020 providing updates to providers on the policy.

2019-06Provider Update

Provider Update published in June 2019 distributing prior policy information to providers.

2018-09Provider Update

Provider Update published in September 2018 with provider-facing notices about bariatric policy items.

2017-07Provider Update

Provider Update published in July 2017 issuing earlier provider guidance related to bariatric surgery coverage.

OpenPayer

Bariatric Surgery

Coverage Criteria and Medical Necessity

Coding and Billing References

Prior Authorization, Billing, and Provider Responsibilities

Background and Policy Scope

Definitions and Terminology

Revision History