Bariatric Surgery (Medical Coverage Policy)
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts
Know when Blue Cross Blue Shield - Rhode Island releases new policies or updates existing guidance.
Monitor payer policy activity
Defines medical necessity, covered and not-covered bariatric surgery procedures and prior authorization requirements for BlueCHiP for Medicare and Commercial products offered by Blue Cross Blue Shield of Rhode Island, affecting providers and members seeking bariatric procedures.
No material clinical or coverage changes in this revision.
Coverage Criteria
BlueCHiP for Medicare - Medical Necessity Criteria
Covered when ALL of the following are met for BlueCHiP for Medicare:
Refer to Benefit Booklet/coverage for contract variations; CMS rules may affect BlueCHiP for Medicare benefits.
These procedures are listed as medically necessary when the medical criteria above are met.
Commercial - Preauthorization and Not Medically Necessary
Commercial product coverage and Not Medically Necessary procedures:
Preauthorization is recommended for Commercial products.
Listed as not medically necessary/insufficient evidence for Commercial products.
Investigational or Insufficient Evidence
Procedures considered investigational or having insufficient evidence:
Adverse events, nutritional complications, and limited controlled trial data cited in clinical literature.
Case series exist for diabetes remission but specialty guidelines do not support routine use; clinical evidence is insufficient for preadolescent children.
Initial coverage
Covered when medical criteria have been met
Preauthorization via payer's web-based tool may be required per related policy; see coding section for specific CPT codes.
Investigational or insufficient evidence
Not covered / Investigational
Use unlisted CPTs for not-covered indications when filing claims (see Claims and coding notes); specialty society guidelines do not support routine surgery in these groups.
Endoscopic device-based procedures (for example, insertion of the StomaphyX™ device, endoscopic gastroplasty, endoscopically placed duodenojejunal sleeves) and intragastric balloons are excluded from coverage as primary bariatric procedures and are also excluded when proposed as revision procedures to treat weight regain after prior bariatric surgery. Published data are limited (small case series and pilot studies), no comparative trials were identified, and available evidence is considered insufficient to support these technologies for primary or revision bariatric indications.
Bariatric surgery is not covered for patients with a body mass index (BMI) of 35 kg/m2 except for limited, specific diabetes indications addressed by specialty guidance; for patients with BMI <35 kg/m2 the procedure is considered investigational. In addition, vertical-banded gastroplasty (CPT 43842) is explicitly not covered for BlueCHiP for Medicare.
The policy lists several open procedures and gastric balloon technology as not covered or not medically necessary: examples include open adjustable gastric banding, open sleeve gastrectomy, open and laparoscopic vertical banding gastroplasty, and gastric balloon for treatment of obesity. Endoscopic procedures (see above) are also considered investigational and are not medically necessary as primary or revision bariatric interventions.
Bariatric surgery in preadolescent children is not supported by sufficient evidence. There are no studies focused specifically on preadolescent children and clinical practice guidelines recommend against performing bariatric surgery in this age group; therefore the evidence is insufficient to determine benefit and surgery is considered not supported for preadolescents.
Coding and Billing
| 43644 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) |
| 43645 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption |
| 43770 | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components) |
| 43771 | Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only |
| 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, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components |
| 43775 | Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) |
| 43845 | Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (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 |
| 43644 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) |
| 43645 | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption |
| 43770 | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components) |
| 43771 | Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only |
| 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, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components |
| 43775 | Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) |
| 43845 | Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (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 |
| 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 |
Provider Actions & Authorization
Prior Authorization Required
Prior authorization is required for BlueCHiP for Medicare and recommended for Commercial products. Participating providers may obtain prior authorizations via the payer's online web-based tool. Lack of required prior authorization may result in denial or nonpayment.
- Prior authorization: BlueCHiP for Medicare — required
- Prior authorization: Commercial products — recommended (via online tool)
Benefit Verification
Verify member benefits, surgery coverage, and any applicable exclusions prior to scheduling surgery. Benefits may vary by group/contract; refer to the member's Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable surgery benefits and for any not medically necessary/not covered determinations.
- Refer to Benefit Booklet / Evidence of Coverage / Subscriber Agreement for applicable surgery benefits and exclusions
Preauthorization and Coding / Claims Notes
The listed CPT codes are covered only when the policy medical criteria are met and preauthorization has been obtained as required. The following CPT codes are considered covered when criteria are met: 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43845, 43846, 43847, 43848. CPT 43842 (vertical-banded gastroplasty) is not covered. For not-covered indications or services without a specific CPT, file claims using the appropriate unlisted CPT (eg, 43659, 43999).
Conservative Therapy and Coverage Thresholds
Patients must have failed conservative medical treatment for obesity prior to meeting coverage criteria. For BlueCHiP for Medicare, bariatric surgery coverage requires a BMI ≥ 35 or a BMI ≥ 35 with at least one obesity-related comorbidity and prior unsuccessful medical treatment for obesity. Bariatric surgery for patients with BMI < 35 is investigational and may be denied.
- Conservative therapy requirement: prior unsuccessful medical treatment for obesity
- BlueCHiP for Medicare coverage threshold: BMI ≥ 35 and/or obesity-related comorbidity
- BMI < 35: investigational — may be denied
Background
Bariatric surgery is performed to treat morbid (clinically severe) obesity when conservative medical management has failed. Morbid obesity is defined as a BMI of >40 kg/m2 or a BMI of >=35 kg/m2 with significant obesity-related comorbidities. Different surgical procedures use restrictive, malabsorptive, or combined mechanisms and have varying risk and efficacy profiles; some procedures lack sufficient evidence and are considered investigational.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.