ModifiedCapital BluecrossPolicy MP 1.015

Bariatric Surgery

Defines medical necessity, investigational indications, and selection criteria for bariatric surgical procedures across age groups (adults, adolescents, preadolescents) and for revisions and concomitant hiatal hernia repair for members of Capital BlueCross.

Policy Summary

PayerCapital Bluecross

PolicyBariatric Surgery

Policy CodePolicy MP 1.015

Change TypeMajor clinical revision (01/23/2025) with investigational reclassification and criteria updates

Effective Date1/1/2026

Next Review DateN/A

Key ActionObtain prior authorization and document failure of conservative weight‑loss measures per MP 1.015 before submitting bariatric surgery requests.

SourceLink

POLICY UPDATE CHANGES

Title changed from Metabolic and Bariatric Surgery to Bariatric Surgery; SADI-S and 2-stage bariatric surgery changed from medically necessary to investigational; hiatal hernia repair changed to investigational unless diagnosed preoperatively; bariatric surgery for preadolescent children changed to investigational; BMI requirements increased and criteria updated to align with BCBSA policy; Esophagogastroduodenoscopy with Bariatric Surgery added as investigational.

Tobacco use clarified to include e-cigarettes/vaped tobacco and marijuana; time frame for tobacco abstinence shortened from 6 months to 6 weeks.

New CPT/HCPCS codes (43290, 43291, C9784, C9785, 0813T, 43889) were added or removed in administrative updates across review history.

BMI ≥40Class 3 threshold

BMI 35–39.9Class 2 threshold

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Evidence Summary

Bariatric surgery — Class 3 adults

Covered when ALL of the following are met for adults with Class 3 obesity

Class 3 eligibility: Adult (age ≥18) with BMI ≥40.0 kg/m2 who have failed weight loss by conservative measuresBMI ≥40.0 kg/m2

Eligible procedures include RYGB, LAGB, sleeve gastrectomy, and biliopancreatic diversion/duodenal switch; see Policy Guidelines for program and surgeon requirements

Bariatric surgery — Class 2 adults with comorbidity

Covered when ALL of the following are met for adults with Class 2 obesity

Class 2 eligibility: Adult with BMI 35.0–39.9 kg/m2 AND at least 1 obesity-related comorbid condition, and failed weight loss by conservative measuresBMI 35.0–39.9 kg/m2

Eligible procedures include RYGB, LAGB, sleeve gastrectomy, and biliopancreatic diversion/duodenal switch; surgery should be performed by experienced surgeons in programs with long-term follow-up

Bariatric surgery — Class 1 with type 2 diabetes

Covered when ALL of the following are met for adults with Class 1 obesity

Class 1 with T2D: Adult with BMI 30.0–34.9 kg/m2 AND diagnosed type 2 diabetes AND failed weight loss by conservative measuresBMI 30.0–34.9 kg/m2

Eligible procedures include RYGB, LAGB, and sleeve gastrectomy; bariatric surgery is investigational for Class 1 without type 2 diabetes

Revision Bariatric Surgery

Revision procedures

Revision surgery indications: Revision surgery to address perioperative or late complications (e.g., staple line failure, obstruction, stricture, non-absorption causing hypoglycemia or malnutrition, ≥20% weight loss below ideal body weight, band slippage not correctable by adjustment) is medically necessaryvaries by indication

Revision for pouch dilation is medically necessary if initial procedure produced weight loss and patient was compliant with nutrition/exercise program; revision for refractory severe GERD is also covered

Bariatric surgery — Adolescents

Adolescents

Adolescent eligibility: Adolescents may be considered for bariatric surgery using weight-based criteria similar to adults, with greater emphasis on developmental maturity, psychosocial status, and informed consent; device use must follow FDA indicationsConsider BMI thresholds paralleling adults; many guidelines reserve surgery for BMI >50 kg/m2 or BMI ≥35 with comorbidities

Procedure selection may differ from adults; LAGB devices are not FDA-approved for <18 years; follow pediatric/ASMBS guidance and program requirements

Adults with Class 3 Obesity

Covered when evidence supports benefit for adults with Class 3 obesity:

Class 3 obesity: Adults (≥18 years) with BMI ≥40 kg/m2 may be treated with bariatric surgery (RYGB, LAGB, LSG, biliopancreatic diversion/duodenal switch)BMI ≥40 kg/m2

RCTs, observational studies, and systematic reviews show greater weight loss and improvements in mortality, T2D, cardiovascular risk factors, and quality of life

Adults with Class 2 Obesity

Covered when evidence supports benefit for adults with Class 2 obesity:

Class 2 obesity: Adults (≥18 years) with BMI 35–39.9 kg/m2 may be treated with bariatric surgery (RYGB, LAGB, LSG, biliopancreatic diversion/duodenal switch) when they have at least one obesity-related comorbidity and have failed conservative measuresBMI 35–39.9 kg/m2

Evidence includes RCTs and systematic reviews showing greater weight loss and improvements in mortality, T2D, CV risk, and quality of life

Adults with Class 1 Obesity and Type 2 Diabetes

Covered when evidence supports benefit for adults with Class 1 obesity and T2D:

Class 1 obesity with T2D: Adults with BMI 30–34.9 kg/m2 and type 2 diabetes may be treated with bariatric surgery (RYGB, LAGB, LSG, biliopancreatic diversion/duodenal switch) if they have failed conservative measuresBMI 30–34.9 kg/m2 with T2D

Systematic reviews and RCTs show greater diabetes remission and HbA1c reduction versus medical therapy though GRADE quality is low to very low; balance benefits against surgical risks

Adults with BMI <35 kg/m2 without Type 2 Diabetes

Not sufficiently supported:

BMI <35 without T2D: Bariatric surgery for individuals with BMI <35 kg/m2 who do not have type 2 diabetes has insufficient evidence to conclude a net health benefitBMI <35 kg/m2 without T2D

Few small RCTs and case series report weight loss and comorbidity improvements but long-term risk-benefit remains unclear

Revision Surgery - Covered

Revision bariatric surgery

Revision surgery coverage: Revision bariatric surgery is supported by systematic reviews, case series, and registry data showing satisfactory weight loss and reduced comorbidities; evidence is sufficient to determine net health benefit

Safety data include e.g., a 7.2% serious complication rate for conversion to RYGB in a large retrospective analysis; submit documentation of prior procedure and indication

Adolescents - Covered with restrictions

Adolescents with obesity

Adolescent coverage: Bariatric surgery in adolescents yields significant weight loss and reduction in comorbidities; generally reserved for individuals with severe comorbidities or BMI >50 kg/m2 and requires consideration of developmental stage, psychosocial aspects, and informed consent capabilityBMI >50 kg/m2 or severe comorbidities

Most guidelines recommend reserving surgery for severe cases; follow pediatric/ASMBS guidance and ensure multidisciplinary evaluation

Adults BMI <35 without T2D - Insufficient

Adults with BMI <35 without Type 2 Diabetes

Adults BMI <35 without T2D: Evidence (small RCTs, case series) shows weight loss and some comorbidity improvements but is insufficient to determine long-term risk-benefit; therefore evidence is insufficient to conclude net health benefitBMI <35 kg/m2 and no T2D

Bariatric surgery in this population is not supported for coverage based on net health outcome

Preadolescents - Insufficient

Preadolescent children with obesity

Preadolescents: No studies focused solely on preadolescents; limited cohort data suggest possible long-term benefit but overall evidence is insufficient to determine net health benefitpreadolescent age group

One prospective noncomparative cohort reported long-term LSG outcomes in children as young as 5 years, but further comparative studies are required

Hiatal Hernia Repair - Covered when preoperative diagnosis present

Hiatal hernia repair when preoperatively diagnosed

Hiatal hernia repair with bariatric surgery: When a preoperative diagnosis of hiatal hernia exists, repair during bariatric surgery (eg, sleeve gastrectomy) is associated with improved GERD remission and fewer complications and is considered medically necessaryPreoperative diagnosis of hiatal hernia

No evidence supports routine repair for incidental hiatal hernia found intraoperatively

EGD - Insufficient for routine preoperative use

Esophagogastroduodenoscopy (EGD) with bariatric surgery

Preoperative EGD: Systematic reviews show only about 20% of preoperative EGDs had findings that altered operative management or postponed surgery; evidence is insufficient to determine that routine preoperative EGD improves net health outcomes

Routine intraoperative or postoperative EGD use is not supported by current evidence

Evidence summaries

Evidence summaries and applicable procedure categories cited in this section

Evidence basis: Includes randomized controlled trials, long-term cohort studies, systematic reviews, and meta-analyses addressing primary bariatric procedures (RYGB, sleeve gastrectomy, biliopancreatic diversion/duodenal switch, adjustable gastric banding), revisional surgery, and endoscopic/device therapies

References cited support the clinical evidence statements in the policy (see reference list)

Major revisions affecting coverage

Policy history documents substantial changes to coverage criteria over time; see MP 1.015 for full current criteria. Notable logical groupings and changes include:

Major 01/23/2025 changes: Title changed to 'Bariatric Surgery'; SADI-S and 2-stage bariatric surgery changed from medically necessary to investigational; hiatal hernia repair changed to investigational unless diagnosed preoperatively; bariatric surgery for preadolescent children changed to investigational; BMI requirements increased and criteria aligned with BCBSA policy; EGD with bariatric surgery added as investigational

See policy history for administrative code updates and prior minor reviews

Eligibility and preoperative program changes

Prior minor reviews and administrative updates introduced or clarified multiple eligibility elements:

Tobacco and pre-op program clarifications: Tobacco use defined to include e-cigarettes/vaped products and marijuana; tobacco abstinence timeframe changed to 6 weeks; multidisciplinary preoperative program guidance updated to follow ASMBS guidelines; mental health evaluation purpose clarifiedTobacco abstinence: 6 weeks

Providers should follow current MP 1.015 for exact preoperative documentation and program participation requirements

The policy identifies multiple procedures and indications as investigational / not covered. Bariatric surgery is considered investigational for adults with Class 1 obesity who do not have type 2 diabetes and for individuals with a BMI <30 kg/m2. Specific primary or revision procedures listed as investigational include vertical-banded gastroplasty, mini‑gastric (Billroth II) bypass, biliopancreatic diversion without duodenal switch, long‑limb gastric bypass (>150 cm), two‑stage bariatric procedures, laparoscopic gastric plication, and single anastomosis duodeno‑ileal bypass with sleeve gastrectomy (SADI‑S). Endoscopic primary or revision procedures considered investigational include StomaphyX insertion, endoscopic gastroplasty, endoscopically placed duodenojejunal sleeves, intragastric balloons, and aspiration therapy. Routine use of esophagogastroduodenoscopy (EGD) with bariatric surgery is also listed as investigational.

These investigational designations were reaffirmed and expanded in the policy history (major review dated 01/23/2025), which updated the title and explicitly listed several procedures and populations as investigational and therefore excluded from coverage under medical necessity criteria.

Liquid‑filled intragastric balloons have documented safety concerns. FDA communications described reported events of spontaneous overinflation causing pain, swelling, and vomiting, as well as cases of acute pancreatitis due to compression of adjacent structures. Subsequent FDA letters noted multiple deaths associated with liquid‑filled balloons and advised clinicians to monitor patients closely for balloon deflation, gastrointestinal obstruction, perforation, acute pancreatitis, and spontaneous hyperinflation throughout the treatment period.

Because of these observed serious adverse events — including reported deaths — the policy emphasizes the need for close monitoring and identifies intragastric balloons among endoscopic/device therapies that are investigational for primary or revision bariatric indications.

The policy lists specific procedure codes designated as investigational and not covered. These include C9785 and the CPT codes 0813T, 43290, 43291, 43645, 43659, 43842, 43847, and 43889 as investigational for the bariatric procedures referenced in the policy.

The policy highlights several endoscopic and device‑based procedures that require additional high‑quality evidence before they can be considered medically necessary. Examples include some endoscopic gastroplasty approaches (systematic reviews note that endoscopic gastroplasty “needs more quality data”), and duodenal‑jejunal (EndoBarrier) liners, which have been the subject of systematic reviews and meta‑analyses assessing efficacy and safety but for which outcomes remain insufficient to support routine coverage.

References cited in the policy include recent systematic reviews and meta‑analyses evaluating duodenal‑jejunal bypass liners and other endoluminal devices, underscoring that current evidence is inadequate to establish long‑term net health benefit for these technologies.

A major review on 01/23/2025 resulted in several substantive coverage changes; notable items changed from medically necessary to investigational include SADI‑S (single anastomosis duodeno‑ileal bypass with sleeve gastrectomy) and two‑stage bariatric surgery. The review also changed the status of hiatal hernia repair performed at the time of bariatric procedures to investigational unless a hiatal hernia was diagnosed preoperatively, and reclassified bariatric surgery for preadolescent children as investigational. The same review designated routine EGD with bariatric surgery as investigational.

Procedures and indications categorized as investigational are considered not medically necessary due to insufficient evidence of net health benefit. This includes, but is not limited to, many listed surgical variants (e.g., long‑limb bypass, BPD without DS), endoscopic therapies (e.g., StomaphyX, endoscopic gastroplasty, intragastric balloons, aspiration therapy), and certain pediatric indications. The policy states that these investigational classifications form the basis for exclusion from coverage when billed as medically necessary procedures.

For adults with BMI <35 kg/m2 who do not have type 2 diabetes, the policy explicitly concludes that current evidence is insufficient to determine long‑term risk–benefit and therefore does not support coverage as medically necessary.

The policy states that for adults with BMI <35 kg/m2 who do not have type 2 diabetes, available trials and case series report short‑term weight loss and some comorbidity improvements, but the evidence base does not permit conclusions about the long‑term risk–benefit balance. As a result, bariatric surgery in this population is considered unsupported by sufficient evidence to conclude a net health benefit.

Restating the policy position: for adult patients with a BMI <35 kg/m2 and no Type 2 diabetes, the evidence (including small randomized trials and case series) is inadequate to establish long‑term improvement in net health outcomes, and therefore bariatric surgery is not supported as medically necessary for this group.

A cited systematic review specifically concluded that endoscopic gastroplasty ‘needs more quality data’, and the policy reflects this by classifying endoscopic gastroplasty as investigational. Multiple referenced trials and reviews of endoluminal techniques emphasize limited and low‑quality evidence, indicating that additional rigorous comparative studies are required before these approaches can be recommended for routine use.

Specific procedures moved to investigational status in the recent major review include SADI‑S and two‑stage bariatric surgery. The policy also maintains investigational status for several other procedures and indications such as vertical‑banded gastroplasty, mini‑gastric bypass (Billroth II), biliopancreatic diversion without duodenal switch, long‑limb gastric bypass (>150 cm), laparoscopic gastric plication, and single anastomosis duodeno‑ileal bypass with sleeve gastrectomy. Endoscopic techniques and routine EGD with bariatric surgery were likewise designated investigational in the updated policy.

Procedure and Diagnosis Codes

FDA-approved bariatric devices (PMA entries)mixed

Obalon (PMA Sept 2016)	Obalon intra gastric balloon system — for use in obese adults (BMI 30–40 kg/m2); maximum placement time 6 months; capsule-swallowed gas-filled balloon
AspireAssist (PMA Jun 2016)	AspireAssist System — for long-term use with lifestyle therapy and monitoring in adults with BMI 35–55 kg/m2
ORBERA (PMA Aug 2015)	ORBERA intragastric balloon system — for use in obese adults (BMI 30–40 kg/m2); maximum placement time 6 months; endoscopically placed and inflated with saline
LAP-BAND (PMA Apr 2010)	LAP-BAND Adjustable Gastric Banding System — for weight reduction in severely obese adults (BMI ≥40 or ≥30 with ≥1 severe comorbidity)
REALIZE (PMA Nov 2007)	REALIZE Adjustable Gastric Band — for morbidly obese adults (BMI ≥40 or ≥35 with ≥1 comorbidity)

Investigational / Not Covered Procedure CodesCPTNot Covered

C9785	Investigational; therefore, not covered for listed bariatric surgery procedures
0813T	Procedure code listed as investigational
43290	Procedure code listed as investigational
43291	Procedure code listed as investigational
43645	Procedure code listed as investigational
43659	Procedure code listed as investigational
43842	Procedure code listed as investigational
43847	Procedure code listed as investigational
43889	Procedure code listed as investigational

Covered when medically necessary - Procedure CodesCPTCovered

43774	Covered when medically necessary (listed with multiple pairings)
43289	Covered when medically necessary (paired to other procedure codes per policy text)
43775	Covered when medically necessary (paired with 43289 per policy text)
43774	Covered when medically necessary (appears as primary code paired with multiple CPTs)
43775	Covered when medically necessary (paired with 43774 in policy examples)
43644	Covered when medically necessary
43843	Covered when medically necessary
43645	Covered when medically necessary
43845	Covered when medically necessary
43659	Covered when medically necessary

1–10 of 20

1/2

Covered Diagnosis / Z codesICD-10Covered

E66.01	Morbid (severe) obesity due to excess calories
K95.09	Other complications of gastric band procedure
K95.89	Other complications of other bariatric procedure
Z46.51	Encounter for fitting and adjustment of gastric lap band
Z68.30	BMI 30.0-30.9, adult
Z68.31	BMI 31.0-31.9, adult
Z68.32	BMI 32.0-32.9, adult
Z68.33	BMI 33.0-33.9, adult
Z68.34	BMI 34.0-34.9, adult
Z68.35	BMI 35.0-35.9, adult

1–10 of 23

1/3

Policy history — codes added/removedmixed

43290	New code added (reference in policy history)
43291	New code added (reference in policy history)
0813T	New code added (reference in policy history)
C9784	Administrative update added code (later removed per 12/11/2025)
C9785	Administrative update added code (later removed per 12/11/2025)
43889	New code added 12/11/2025

ICD-10 codes referenced in historyICD-10

Z68.30 - Z68.45	ICD-10 codes added (policy history)
Z68.52 - Z68.54	ICD-10 codes added (policy history)

BMI thresholds — adult eligibility

Class 3 (most severe)BMI ≥40.0 kg/m2 — adults (age ≥18) eligible when conservative measures have failed

Class 2BMI 35.0–39.9 kg/m2 — adults eligible only with at least one obesity‑related comorbid condition and failure of conservative measures

Class 1 (with T2D)BMI 30.0–34.9 kg/m2 — adults eligible only if type 2 diabetes is present and conservative measures have failed

BMI thresholds for discussed evidence groups

Evidence group — Class 3BMI ≥40 kg/m2 (discussed as Class 3 evidence group)

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Program- and product-specific prior authorization

Prior authorization requirements vary by product and program. Verify whether the member’s specific Capital BlueCross product or program requires prior authorization for bariatric procedures and follow any additional, product-specific rules (for example, FEP PPO follows the FEP Medical Policy Manual).

Check member benefit plan and program-specific guidance before scheduling.
FEP PPO: refer to FEP Medical Policy Manual at https://www.fepblue.org/benefit-plans/medical-policies-and-utilization-managementguidelines/medical-policies.

Prior Authorization

Prior authorization may be required

Prior authorization may be required for bariatric and related endoscopic or revisional procedures. Presence of a code in this policy or on a claim does not guarantee coverage — eligibility, member benefits, and medical necessity must be verified on the date of service.

Verify member eligibility and benefits on the date of service.
Obtain prior authorization when required by the member’s benefit plan prior to performing the service.

Background and Clinical Context

Bariatric surgery encompasses operations that reduce gastric volume and/or intestinal absorption to produce weight loss and reduce obesity‑related comorbidities. Procedure selection is individualized and considers the patient’s BMI class (e.g., Class 3: ≥40 kg/m2; Class 2: 35–39.9 kg/m2), presence of obesity‑related conditions (such as type 2 diabetes), expected magnitude of weight loss required, and the risk profile of the operation (for example, greater risk of long‑term nutritional deficiencies with malabsorptive procedures).

Other important considerations include prior failure of conservative measures (documented dietary/lifestyle efforts or formal weight‑reduction programs), age and developmental maturity for adolescents, and potential need for revision procedures when complications or inadequate weight loss occur. The policy and supporting guidelines referenced (ASMBS and others) guide these clinical determinations and preoperative requirements.

Key Definitions

Weight-related complications

Type 2 diabetesListed as a weight-related complication caused or exacerbated by excess adiposity

Obstructive sleep apneaNamed as a weight-related complication

Hypertension and cardiovascular diseaseIncluded among obesity-related comorbid conditions

Gastroesophageal reflux disease (GERD)Included as a weight-related complication

Nonalcoholic fatty liver disease and dyslipidemiaListed as weight-related complications

Failure of conservative measures — definition and examples

Definition

Policy Revisions and Administrative Updates

2025-01-23major_reviewLatest

Major review: title changed from 'Metabolic and Bariatric Surgery' to 'Bariatric Surgery'; SADI-S and 2‑stage bariatric surgery moved from medically necessary to investigational; hiatal hernia repair made investigational unless diagnosed preoperatively; bariatric surgery for preadolescent children changed to investigational; BMI requirements increased and criteria aligned with BCBSA policy; esophagogastroduodenoscopy with bariatric surgery listed as investigational.

2021-09-29eligibility_revision

Minor review clarified tobacco use to include e-cigarettes/vaped products and marijuana, and shortened the tobacco abstinence timeframe from 6 months to 6 weeks; additional preoperative program and adolescent criteria updates implemented.

Policy Summary

PayerCapital Bluecross

PolicyBariatric Surgery

Policy CodePolicy MP 1.015

Change TypeMajor clinical revision (01/23/2025) with investigational reclassification and criteria updates

Effective Date1/1/2026

Next Review DateN/A

Key ActionObtain prior authorization and document failure of conservative weight‑loss measures per MP 1.015 before submitting bariatric surgery requests.

SourceLink

On This Page

Prior Authorization

Prior authorization expected for revisional and endoscopic bariatric procedures

Revisional and endoscopic bariatric procedures commonly require prior authorization and detailed supporting documentation. Requests for revision (surgical or endoscopic) should include the indication, prior operative details, and objective evidence supporting the need for revision.

Include prior procedure(s) date(s), operative report(s), and pathology or imaging results as applicable.
Document the complication or objective findings prompting revision (e.g., staple-line failure, obstruction, pouch dilation, band slippage, GERD refractory to medical therapy, malnutrition, or weight regain).

Billing Rule

Use current codes and confirm investigational status

Use current procedure, diagnosis, and administrative codes when requesting authorization and when billing. Confirm whether specific endoscopic or device therapies are considered investigational or excluded under current policy and product benefits prior to approval or submission of claims.

Code lists in this policy may not be all-inclusive and are subject to change — verify up-to-date codes.
Confirm investigational status for newer endoscopic/device therapies (e.g., some intragastric balloons, aspiration therapy, percutaneous gastrostomy devices, or novel endoluminal devices) before authorization; investigational designations may result in noncoverage.

Denial Risk

Coverage denials may be triggered

Coverage denials may be triggered when required documentation is missing, when procedures are investigational per the policy, or when member benefits do not provide coverage. Investigational procedure exclusions or changes in policy status can result in denials even if codes exist for billing.

Missing documentation of conservative therapy failure, lack of prior authorization when required, or insufficient rationale for revision are common reasons for denial.
Procedures specifically designated investigational in MP 1.015 (or by product benefit) are not covered and may be denied.

Documentation Required

Revision surgery documentation

Revision surgery requests must document the complication or objective evidence that supports the need for revision, including prior operative details, evidence of initial success (if applicable), and prior non-surgical management attempts.

Provide prior operative report(s), dates, and any post-operative imaging or endoscopy demonstrating the complication (e.g., pouch dilation documented by upper GI exam or endoscopy).
Document compliance with prescribed nutrition and exercise programs when failure of a prior procedure is claimed.

Documentation Required

EGD documentation

When an EGD is performed in the preoperative evaluation, include the indication for the procedure and detailed findings in the request. Document any abnormalities that affect surgical planning or require preoperative treatment (for example, large hiatal hernia, peptic ulcer disease, or Helicobacter pylori infection).

Report whether EGD was performed due to symptoms or at surgeon discretion and include endoscopy findings and any biopsies or treatments.
If EGD is not routinely performed, document the clinical indication per current guidance (ASMBS/AGA recommendations).

Prior Authorization

Eligibility and medical necessity verification

Verify member eligibility, benefits, and medical necessity prior to authorizing or providing bariatric services. Authorization or coding in this policy does not guarantee payment — final claim adjudication is based on the member’s contract terms and date-of-service eligibility.

Confirm eligibility and coverage on the date of service via Provider Services or the payer portal.
Ensure medical necessity is documented to support the requested service per MP 1.015 criteria.

Documentation Required

When requesting revisional bariatric surgery

When requesting revisional bariatric surgery or endoscopic revision, include prior procedure details, documentation of the complication or failure, evidence of prior conservative and device-specific management, and objective diagnostic findings that justify the revision.

Supply operative reports, endoscopy/upper GI imaging, weight trends, nutrition assessments, and records of prior non-surgical interventions.
Describe the goals of revision (e.g., correct obstruction, address malnutrition, treat refractory GERD, or manage clinically significant weight regain).

Note

Follow current MP 1.015 eligibility and coding guidance

Follow the current MP 1.015 eligibility criteria and coding guidance when preparing authorization requests and claims. Policy history and administrative updates have changed eligibility, investigational status of procedures, and coding; ensure you are using the latest policy effective/version date.

Refer to the most recent policy updates and the policy history for changes to investigational designations and code additions/deletions.
Use current effective dates and code lists when submitting requests and claims.

Documentation Required

Conservative therapy prerequisite

Patients must have documented failure of conservative weight-loss measures before bariatric surgery is considered. Documentation of non-surgical interventions and participation in a multidisciplinary preoperative program (per current criteria and professional society guidance) is required for most authorizations.

Document prior weight-loss attempts, duration, frequency, dietary and exercise regimens, and participation in any formal preoperative weight reduction program.
Some centers require active participation with regular documentation of weight, dietary regimen, and exercise; lack of documentation may lead to non-approval.

Documentation Required

Adolescent selection considerations

For adolescents, bariatric surgery should be reserved for individuals with severe comorbidities or very high BMI (for example, BMI >50 kg/m2) after failure of conservative therapy; consider developmental stage, psychosocial factors, and ability to provide informed consent. Additional adolescent-specific contraindications and criteria in MP 1.015 must be met and documented.

Ensure documentation of severity of comorbidities and prior conservative management.
Confirm that adolescent-specific selection criteria and contraindications from MP 1.015 are addressed in the record.

Prior Authorization

Some endoscopic or device-based therapies

Some endoscopic or device-based therapies are evaluated in this policy and may have unique prior authorization, documentation, or investigational designations. Confirm the device or endoscopic procedure status under MP 1.015 and the member’s product benefits before approval or billing.

Examples include intragastric balloons, aspiration therapy, percutaneous gastrostomy devices, and various endoluminal revision techniques — these may be investigational or have special requirements.
Provide device-specific clinical rationale, prior response to conservative therapy, and any required preprocedure testing when requesting authorization.

Documentation Required

Conservative therapy documentation required per current criteria

Conservative therapy documentation is required per current MP 1.015 criteria. Failure to document prescribed conservative measures, their duration, and outcomes may result in denial of bariatric surgery authorization.

Include dates, types, and results of prior nonsurgical treatments and evidence of participation in a multidisciplinary preoperative program per ASMBS guidance when applicable.
Document any medical reasons why standard conservative therapy was not appropriate or feasible for the patient.

Revisional bariatric surgery — definition and typical indications

DefinitionSurgical procedures performed to convert or revise a prior bariatric operation (e.g., sleeve gastrectomy to Roux‑en‑Y gastric bypass)

Typical indicationsFailure to achieve adequate weight loss, complications (staple‑line failure, obstruction, stricture, malnutrition, band slippage), refractory severe GERD, or weight regain

EvidenceSystematic reviews, cohort studies, and registry data support revision surgery with acceptable outcomes but require documentation of prior procedure and indication

2022-12-20policy_history_update

Minor review added ICD‑10 codes Z68.30–Z68.45 and Z68.52–Z68.54 and made other criteria adjustments (title changed at that time to 'Metabolic and Bariatric Surgery' in the record).

2023-06-13code_change

Administrative update added codes C9784 and C9785 (effective 07/01/2023).

2023-12-12code_change

Administrative update added code 0813T (effective 01/01/2024).

2025-12-11code_change

Administrative update added new code 43889 and removed deleted code C9784 (noted with effective date 01/01/2026).