CurrentCareSource GeorgiaPolicy GA-MED-P-5297750

Metabolic and Bariatric Surgery

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This policy governs medical necessity, documentation, contraindications, and referral requirements for metabolic and bariatric surgery for CareSource members aged 13 years and older, including surgical treatment of obesity and related metabolic conditions.

Policy Summary

PayerCareSource Georgia

PolicyMetabolic and Bariatric Surgery

Policy CodePolicy GA-MED-P-5297750

Change TypeAdded Asian-specific BMI thresholds

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionSubmit the clinical criteria and supporting documentation required by this policy for prior authorization.

SourceLink

POLICY UPDATE CHANGES

Asian-specific BMI thresholds were added to the medical necessity criteria for metabolic and bariatric surgery.

13+ yearsMinimum member age

≥35 kg/m²BMI threshold: most members

≥32.5 kg/m²BMI threshold: Asian members

6 monthsBehavioral health evaluation

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CurrentCareSource GeorgiaPolicy GA-MED-P-5297750

Metabolic and Bariatric Surgery

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Sign up for caresourcegeorgia Policy GA-MED-P-5297750 alerts

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Policy Summary

PayerCareSource Georgia

PolicyMetabolic and Bariatric Surgery

Policy CodePolicy GA-MED-P-5297750

Change TypeAdded Asian-specific BMI thresholds

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionSubmit the clinical criteria and supporting documentation required by this policy for prior authorization.

SourceLink

POLICY UPDATE CHANGES

Asian-specific BMI thresholds were added to the medical necessity criteria for metabolic and bariatric surgery.

13+ yearsMinimum member age

≥35 kg/m²BMI threshold: most members

≥32.5 kg/m²BMI threshold: Asian members

6 monthsBehavioral health evaluation

1 yearPostoperative pregnancy avoidance

>55 kg/m²Comprehensive center referral

Medical Necessity and Coverage Criteria

Initial Medical Necessity Criteria

Covered when all of the following are met. A mandatory preoperative weight-loss regimen is not required before surgery.

ALL of the following

Primary diagnosis of obesity
Member is 13 years of age or older>= 13 years
ONE of the following BMI requirements
- BMI is 35 kg/m² or greater; for Asian patients, BMI is 32.5 kg/m² or greaterBMI >= 35 kg/m² (>= 32.5 kg/m² for Asian patients)
- BMI range plus serious obesity-related condition
  - BMI is 30 to 34.9 kg/m²; for Asian patients, BMI is 27.5 to 32.4 kg/m²BMI 30–34.9 kg/m² (27.5–32.4 kg/m² for Asian patients)
  - At least ONE serious obesity-related condition
    High risk for type II diabetes, including insulin resistance, prediabetes, and/or metabolic syndrome
    Osteoarthritis of the knee or hip
    Improving outcomes of knee or hip replacement
    Obstructive sleep apnea; CPAP should be considered before surgery
    Non-alcoholic fatty liver disease
- Type II diabetes pathway
  - BMI is greater than 30 kg/m²BMI > 30 kg/m²
  - Type II diabetes mellitus is inadequately controlled despite optimal medical treatment with oral or injectable medications, including insulin
    Documentation of inadequate control despite optimal treatment is required.

Required Clinical Documentation

Written clinical documentation and supporting information from the attending surgeon must include all of the following.

ALL of the following

Evidence of informed consent
Primary care or specialist letter
- Letter from the primary care physician or appropriate specialist documenting the medical necessity for the procedure
- Letter addresses health-related behaviors, such as smoking history or adherence
Multidisciplinary program participation
- Evidence that the member is receiving treatment in a multidisciplinary program

Referral to an Accredited Comprehensive Center

Members meeting the following referral trigger should be referred to an accredited comprehensive center.

ANY of the following

BMI is greater than 55 kg/m²BMI > 55 kg/m²
Member has additional issues identified for referral under this policy
The source excerpt identifies this referral category but does not specify the additional issues.

Surgery is contraindicated and not covered in the following circumstances: a medically correctable cause of obesity; current pregnancy or planned pregnancy within one year of the procedure; active suicidality or self-harm; active psychosis; active substance use disorder or ongoing substance abuse within the previous year; severe coagulopathy; uncontrolled and untreated eating disorders; or inability to comply with postoperative long-term follow-up care.

The intended procedure is not covered if it is experimental or investigational. Examples include, but are not limited to, endoscopic sleeve gastroplasty (ESG) and aspiration therapy (AT).

BMI Pathways and Referral Thresholds

BMI Pathway 1

Standard thresholdBMI ≥35 kg/m²

Asian patient thresholdBMI ≥32.5 kg/m²

Eligibility pathwayThis is one of the BMI requirements for metabolic and bariatric surgery when other medical necessity criteria are met.

BMI Pathway 2

Standard BMI rangeBMI 30 to 34.9 kg/m²

Asian patient BMI rangeBMI 27.5 to 32.4 kg/m²

Additional requirementAt least one serious obesity-related condition is required, such as obstructive sleep apnea, osteoarthritis of the knee or hip, non-alcoholic fatty liver disease, gastroesophageal reflux disease, or poorly controlled hypertension on multiple drug therapy.

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Obtain prior authorization before submitting metabolic and bariatric surgery for coverage. The procedure is included on the plan’s prior authorization list; providers must submit the authorization request with the required clinical documentation.

Documentation Required

Surgeon and Referring Provider Documentation

The attending surgeon must submit written clinical documentation and supporting information demonstrating medical necessity and informed consent. Documentation must also include a letter from the PCP or appropriate specialist addressing medical necessity and relevant health-related behaviors, such as smoking history or adherence.

Evidence of informed consent is required.
The surgeon’s submission must include the required clinical documentation and supporting information.
The PCP or specialist letter must address medical necessity and health-related behaviors.

Clinical Background

Obesity is associated with significant comorbidities and health risks, including hypertension, type 2 diabetes, hyperlipidemia, cardiovascular disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, and certain cancers. Metabolic and bariatric surgery may improve weight and related metabolic conditions, including diabetes, hypertension, sleep apnea, and hypercholesterolemia, particularly for members who have been unable to manage severe obesity through nonsurgical interventions.

Key Terms

Body Mass Index (BMI) for Adults

DefinitionBody Mass Index (BMI) for Adults is a person's weight in kilograms divided by the square of height in meters.

Weight unitKilograms

Height unit and calculationHeight is measured in meters and squared before dividing the person's weight by it.

Substance Use Disorder (SUD)

DefinitionA cluster of cognitive, behavioral, and physiological symptoms indicating continued use of substances despite significant substance-related problems.

Diagnostic frameworkThe concept encompasses 10 separate classes of drug criteria.

Reference standard

Policy Summary

PayerCareSource Georgia

PolicyMetabolic and Bariatric Surgery

Policy CodePolicy GA-MED-P-5297750

Change TypeAdded Asian-specific BMI thresholds

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionSubmit the clinical criteria and supporting documentation required by this policy for prior authorization.

SourceLink

On This Page

Non-alcoholic steatohepatitis

Gastroesophageal reflux disease

Severe urinary stress incontinence

Poorly controlled hypertension requiring multiple drug therapy

The program must provide ALL of the following

Preoperative medical consultation
Preoperative mental health consultation
Nutritional counseling
Exercise counseling
Patient support programs

Substance use screening results

Evidence that harm reduction related to substance use was discussed

Evidence that the risks of nicotine were discussed

Evidence that vitamin B deficiencies were monitored and treated as needed before surgery

Evidence that the member is free of endocrine disease, supported by an endocrine study consisting of T3, T4, blood sugar, and a 17-Keto Steroid or Plasma Cortisol

Behavioral health evaluation within the past 6 months

Documentation that the member was evaluated within the past 6 months by the treating behavioral health provider
List of co-existing psychiatric conditions
Family and social support
Evidence that the member understands the surgical procedure and can make a responsible decision
Evidence that the member is stable enough to
- Understand the risks and benefits
- Change lifestyle through diet moderation and strategic eating
- Follow through with the extensive aftercare plan
- Withstand the rigors of surgery
- Not display signs of suicidality or significant decompensation if the procedure is unsuccessful

Complete history and physical

Complete history and physical, including an assessment, diagnoses, height, weight, BMI, and treatment plan
Documentation excludes or diagnoses genetic or syndromic obesity, such as Prader-Willi syndrome

For women with reproductive capacity

Appropriate conception counseling was discussed and documented
Clear documentation that the member agreed to avoid pregnancy for at least 1 year after surgery
Discussion of potential birth defects from nutritional deficiencies that may occur if pregnancy occurs during the postoperative weight-stabilization period

BMI Pathway 3

BMI thresholdBMI >30 kg/m²

Required conditionType II diabetes mellitus must be inadequately controlled.

Treatment requirementDocumentation must show inadequate control despite optimal medical treatment with oral or injectable medications, including insulin.

Comprehensive Center Referral

Referral thresholdBMI >55 kg/m²

Referral destinationRefer the member to an accredited comprehensive center.

Referral circumstanceReferral is required rather than performing the procedure in the usual setting when the threshold or other listed complex conditions apply.

Documentation Required

Multidisciplinary Program Required

Document that the member is receiving treatment through a multidisciplinary program capable of providing all required preoperative and ongoing support services.

Preoperative medical consultation
Preoperative mental health consultation
Nutritional counseling
Exercise counseling
Patient support programs

Documentation Required

Substance Use, Nicotine, and Vitamin Documentation

Include documentation of substance-use screening and counseling before surgery, along with monitoring and treatment of vitamin deficiencies as needed.

Substance-use screening results
Discussion of harm reduction related to substance use
Discussion of the risks of nicotine
Evidence that vitamin B deficiencies were monitored and treated as needed before surgery

Documentation Required

Endocrine Evaluation Required

Document that the member is free of endocrine disease based on the required endocrine study.

The endocrine study must include T3, T4, blood sugar, and either a 17-Keto Steroid or Plasma Cortisol.
The record must support that the member is free of endocrine disease.

Documentation Required

Behavioral Health Evaluation

A treating behavioral health provider must evaluate the member within 6 months before surgery and document psychological readiness, support, and ability to comply with surgery and aftercare.

List co-existing psychiatric conditions and assess family and social support.
Document that the member understands the procedure and can make a responsible decision.
Document stability sufficient to understand risks and benefits, change eating and lifestyle behaviors, follow the extensive aftercare plan, and withstand surgery.
Document no signs of suicidality or significant decompensation if the procedure is unsuccessful.

Documentation Required

History and Physical Required

Provide a complete history and physical with the member’s clinical assessment, diagnoses, measurements, and treatment plan. The record must also address genetic or syndromic obesity, including its exclusion or diagnosis.

Assessment and diagnoses
Height, weight, and BMI
Treatment plan
Exclusion or diagnosis of genetic or syndromic obesity, such as Prader-Willi Syndrome

Documentation Required

Conception Counseling

For women with reproductive capacity, document conception counseling and the member’s agreement to avoid pregnancy for at least 1 year after surgery.

Discuss and document the potential birth defects associated with nutritional deficiencies during the postoperative weight-stabilization period.
Document clear agreement to avoid pregnancy for at least 1 year postoperatively.

Denial Risk

Contraindications and Noncovered Procedures

Do not proceed when a listed contraindication is present, and do not submit experimental or investigational procedures for coverage.

Medically correctable cause of obesity
Current pregnancy or planned pregnancy within 1 year of the procedure
Active suicidality or self-harm; active psychosis
Active substance use disorder or ongoing substance abuse within the previous year
Severe coagulopathy
Uncontrolled and untreated eating disorder
Inability to comply with long-term postoperative follow-up care
Endoscopic sleeve gastroplasty (ESG) and aspiration therapy (AT) are experimental or investigational and not covered

Denial Risk

Experimental or Investigational Procedures

Experimental or investigational procedures are not covered under this policy, including endoscopic sleeve gastroplasty and aspiration therapy.

Endoscopic sleeve gastroplasty (ESG)
Aspiration therapy (AT)

Denial Risk

Failure to Meet Medical Necessity Criteria

Coverage may be denied when the member does not meet the required diagnosis, age, BMI, or obesity-related medical-necessity criteria.

Primary diagnosis must be obesity.
Member must be 13 years of age or older.
BMI must be at least 35 kg/m², or at least 32.5 kg/m² for Asian patients.
For BMI 30–34.9 kg/m², or 27.5–32.4 kg/m² for Asian patients, at least one serious obesity-related condition must be documented, such as high risk for type 2 diabetes, knee or hip osteoarthritis, improved knee or hip replacement outcomes, obstructive sleep apnea, non-alcoholic fatty liver disease or steatohepatitis, pseudotumor cerebri, gastroesophageal reflux disease, severe urinary stress incontinence, or poorly controlled hypertension requiring multiple medications.
BMI greater than 30 kg/m² with type 2 diabetes requires documentation that diabetes remains inadequately controlled despite optimal oral or injectable medical treatment, including insulin.
A mandatory preoperative weight-loss regimen is not required.

The criteria are described in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.

Behavioral Health Provider

QualificationA provider of behavioral health services at a minimum master's level.

Provider examplePsychologist

Provider examplesPsychiatrist or psychiatric nurse practitioner

Weight Loss Surgery

Alternate terminologyWeight loss surgery is also known as bariatric and metabolic surgery.

Purpose of terminologyThe terms reflect the impact of these operations on patients' weight and the health of their metabolism.

Related health effectsThese operations can treat obesity and are also effective in treating diabetes, high blood pressure, sleep apnea, and high cholesterol, among other diseases.