CurrentCentenePolicy CP .MP.37

Clinical Policy: Bariatric Surgery

Defines medical necessity criteria, preoperative evaluation, repeat/conversion surgery indications, investigational and not medically necessary bariatric procedures, and coding guidance for bariatric surgery for members/enrollees of Centene-affiliated health plans. This is part 1 of 2; includes policy statements, background, investigational procedures, not medically necessary procedures, and CPT/HCPCS coding lists present in this part.

Policy Summary

PayerCentene

PolicyClinical Policy: Bariatric Surgery

Policy CodePolicy CP .MP.37

Change TypeMultiple revisions (criteria, coding, preop consolidation, investigational wording)

Effective Date

Next Review Date

Key ActionObtain and document nutritional evaluation, medical clearance, and psychiatry/psychology consultation within 6 months prior to surgery and maintain documentation of prior nonsurgical weight loss attempts and comorbidity control.

SourceLink

POLICY UPDATE CHANGES

Multiple annual revisions updated BMI thresholds for Asian ethnicities, moved Type 2 diabetes to absolute comorbidity, added and clarified numerous comorbidities and preoperative requirements across 2020-2024 revision history.

Reworded investigational language from 'investigational' to 'current medical literature is inadequate to determine safety, efficacy and long-term outcomes' for several procedures.

Added CPT and HCPCS code lists as supporting or not supporting medical necessity (various codes added/removed in multiple revisions).

Corrected policy statement I to require requirements in I.A and I.B to be met instead of L.A-C.

Consolidated preoperative evaluation and medical clearance requirements into L.B.1 through L.B.3 replacing prior L.B. and L.C.

Added chronic kidney disease, infertility, polycystic ovarian syndrome, and heart failure to specified criteria lists; added unstable angina and recent MI (within 60 days) to cardiovascular exclusions/considerations.

Removed one-anastomosis gastric bypass in Criteria III.L as duplicative.

Removed requirement for Helicobacter pylori screening.

Updated L.B.4 to require monthly nutritional counseling and L.B.9 to require GI screening/treatment documentation prior to surgery.

Updated verbiage to clarify nonalcoholic fatty liver disease or nonalcoholic steatohepatitis in criteria.

Updated background and references; stated no impact on clinical criteria in some edits.

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≈20CPT codes listed

17Investigational procedures (Part 1)

6Not medically necessary (Part 1)

MultipleGuideline citations

Updated2025 revision activity

Coverage Summary

This policy (CP .MP.37) defines medical necessity criteria, preoperative evaluation, repeat/conversion indications, investigational and not medically necessary bariatric procedures, and coding guidance for bariatric surgery for members/enrollees of Centene-affiliated health plans. Part 1 of 2 contains policy statements, background, investigational and not medically necessary procedure lists, and CPT/HCPCS coding tables.

Scope: applies to adults and adolescents considered for bariatric operations (restrictive and/or malabsorptive procedures) when specified clinical criteria and preoperative evaluations are met. Covered procedures are supported by listed CPT/HCPCS codes; a separate list identifies codes that do NOT support medical necessity.

High-level coverage stance: procedures such as LSG, RYGB, LAGB, and BPD-DS are included in covered considerations when criteria are met; several procedures are labeled investigational/insufficient evidence (e.g., mini/one-anastomosis gastric bypass, endoscopic sleeve gastroplasty, gastric balloons, AspireAssist among others) and others are not medically necessary (e.g., jejunoileal bypass, classic BPD/Scopinaro, VBG, gastric pacing).

Key thresholds (see policy thresholds): adult BMI major threshold ≥ 40 kg/m2 (or ≥140% of the 95th percentile, whichever is lower); adult BMI with comorbidity threshold ≥ 35 kg/m2 plus ≥1 obesity-related comorbidity not improved with nonsurgical methods; modified Asian adult thresholds (policy-specified ≥ 32.5 kg/m2 or ≥ 27.5 kg/m2 with comorbidity); adolescent BMIZ thresholds and repeat-surgery timing (previous surgery ≥ 2 years prior; ≥ 2 months interval after LAGB removal for conversion) are applied as stated in the policy text.

Key thresholds

Adult BMI major threshold≥ 40 kg/m2 or ≥ 140% of the 95th percentile (whichever is lower)

Adult BMI with comorbidity threshold≥ 35 kg/m2 with one or more obesity-related comorbidities not improved with nonsurgical methods

Asian adult BMI thresholdsFor South Asian, Southeast Asian, East Asian adults: BMI thresholds modified to ≥ 32.5 kg/m2 or ≥ 27.5 kg/m2 with comorbidity per policy text

Adolescent BMI thresholdsIf LSG or laparoscopic RYGB requested: BMIZ ≥ 35 kg/m2 or ≥ 120% of the 95th percentile with ≥1 severe uncontrolled comorbidity; policy also references BMIZ ≥ 40 kg/m2 or 140% of the 95th percentile elsewhere

Repeat surgery timingPrevious bariatric surgery at least 2 years prior to repeat procedure

Minimum interval after LAGB removalAt least 2 months between band removal and subsequent bariatric procedure when conversion requested due to eroded LAGB

Failed weight loss definitionWeight loss from the initial procedure was less than 50% of the member/enrollee's excess body weight at time of the initial procedure

Medical-Necessity Criteria

Initial bariatric surgery — medical necessity

Covered when ALL of the following criteria are met:

ALL of the following

Age and BMI (adult or adolescent)
- Adult (≥18 years)
  - BMI ≥ 40 kg/m2 OR ≥ 100% of the 95th percentile for age/sex when applicable
    Include documented height/weight and BMI calculation within 6 months of surgery
  - OR BMI ≥ 35 kg/m2 with at least one significant obesity-related comorbid condition not adequately controlled by medical therapy
    Comorbid conditions include but are not limited to: type 2 diabetes mellitus, hypertension, obstructive sleep apnea, dyslipidemia, nonalcoholic fatty liver disease/NASH, obesity hypoventilation syndrome, ischemic heart disease, heart failure, atrial fibrillation, chronic kidney disease, gastroesophageal reflux disease, venous stasis disease, asthma, severe osteoarthritis or other disabling joint disease, infertility related to obesity, pseudotumor cerebri

Investigational / Insufficient Evidence Procedures

Procedures considered investigational / insufficient evidence

The current medical literature is inadequate to determine safety, efficacy, and long-term outcomes for the following procedures:

Investigational / insufficient evidence procedures

Mini gastric bypass / one-anastomosis gastric bypass / single anastomosis bypass / omega loop gastric bypass
Distal gastric bypass (very long limb gastric bypass)
Laparoscopic re-sleeve gastrectomy (LRSG) performed after dilation of original LSG pouch
Laparoscopic greater curvature plication (gastric imbrication)

Procedures Not Medically Necessary

Procedures considered not medically necessary

The following procedures are considered not medically necessary due to potential complications and lack of positive outcomes:

Not medically necessary procedures

Jejunoileal bypass (jejuno-colic bypass)
Biliopancreatic diversion (BPD) / Scopinaro procedure
Vertical banded gastroplasty (VBG)
Gastric wrapping
Gastric pacing / gastric electrical stimulation

Coding

CPT codes that support medical necessityCPTCovered

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, restrictive procedure; placement of adjustable gastric restrictive device (eg, 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 (ie, sleeve gastrectomy).
43843	Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty.
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).

1–10 of 17

1/2

CPT codes that do NOT support medical necessityCPTNot Covered

43290	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon.
43291	Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s).
43632	Gastrectomy, partial, distal; with gastrojejunostomy.
43647	Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum.
43648	Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum.
43842	Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty.
43847	Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption.
43881	Implantation or replacement of gastric neurostimulator electrodes, antrum, open.
43882	Revision or removal of gastric neurostimulator electrodes, antrum, open.
64590	Insertion or replacement of peripheral or neurostimulator generator or receiver, direct or inductive coupling (gastric pulse).

1–10 of 11

1/2

HCPCS codes that support medical necessityHCPCSCovered

S2083

Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline.

Medicare NCD referencedmixed

NCD 100.1

National coverage determination: bariatric surgery for treatment of co-morbid conditions related to morbid obesity

Provider Actions & Documentation Requirements

Documentation Required

Preoperative clearance and evaluations

Obtain and document preoperative evaluations within six months prior to surgery, including nutrition, medical clearance, and age-appropriate psychiatry/psychology consultation. Maintain documentation of prior nonsurgical weight loss attempts and status of comorbidity control.

Nutritional evaluation
Medical clearance (PCP or specialist as indicated)
Psychiatry/psychology consult
Prior nonsurgical weight loss attempts

Documentation Required

Repeat surgery justification

For repeat or conversion bariatric procedures, document the clinical reason the initial procedure failed and provide objective evidence that coverage criteria are met again. Include specific timing and outcome data, and evidence of adherence to prior postoperative recommendations.

Previous surgery at least ≥ 2 years prior to repeat procedure

Background & Evidence

Background/rationale: Individuals with clinically severe obesity face increased mortality and multiple comorbidities (eg, hypertension, diabetes, dyslipidemia, obstructive sleep apnea, degenerative arthritis and psychosocial impairments). Surgical treatment is the only proven method for achieving long-term weight control in morbid obesity; most patients who lose weight nonoperatively regain the weight within five years and maximal postoperative weight loss typically occurs between 18–24 months.

Common procedures and mechanisms: bariatric operations are categorized as restrictive (creating a small gastric pouch to limit intake — e.g., LAGB, LSG) and malabsorptive (bypassing portions of stomach/intestine to reduce absorption — e.g., RYGB, duodenal switch/BPD-DS). RYGB has long-term established results; LSG is the most commonly performed procedure with lower complication/nutritional deficiency rates while maintaining comparable weight-loss and metabolic outcomes; BPD-DS yields large weight loss but greater long-term nutritional risk.

Outcomes and complications: average long-term excess weight loss varies by procedure (examples in policy: 48–74% at five years after gastric bypass; 50–60% following gastric banding) and 10% of patients may have unsatisfactory weight loss or regain. Malabsorptive procedures carry higher risk of long-term nutritional deficiencies; procedural selection should consider BMI, comorbidity profile, goals, surgeon expertise, patient preference and risk stratification.

Multidisciplinary care and perioperative needs: success depends on patient motivation and long-term follow-up; the policy requires preoperative nutritional, medical and age-appropriate psychiatric/psychology evaluations and ongoing multidisciplinary support including perioperative nutritional management and long-term monitoring, especially for procedures with known nutritional risks.

Adolescent considerations: severe adolescent obesity carries similar comorbid risks as adults; multi-disciplinary, family-based approaches are required. ASMBS pediatric guidance supports metabolic and bariatric surgery as a proven, effective treatment and standard of care for selected adolescents when guideline criteria are met; LAGB is used less in adolescents in favor of sleeve gastrectomy.

Medicare Determinations

Name	Effective Date	Number
CMS National Coverage Determination for bariatric surgery - Bariatric surgery for treatment of co-morbid conditions related to morbid obesity	2013-09-24	100.1
CMS National Coverage Determination referenced (general policy reference)		(NCD referenced in policy; number not specified in brief)

Perioperative & Pre-Surgical Requirements

Preoperative care and screening updates

Preoperative care and screening updates (summarized; full operational details in Part 1):

Monthly nutritional counseling required (updated Criterion L.B.4).
Gastrointestinal (GI) screening and evaluation for clinically significant GI symptoms with documentation of needed treatment prior to bariatric surgery (updated Criterion L.B.9).
Removed Helicobacter pylori screening requirement (removed Criterion I.B.10).
Corrected policy statement I to require I.A and I.B to be met (revision 04/25).

Preoperative evaluations consolidated into L.B.1 through L.B.3

Revision History

2014-03-24 to 03/24 (multiple annual revisions through 2024)material

03/23non-material

Reworded investigational language from 'investigational' to 'current medical literature is inadequate to determine safety, efficacy and long-term outcomes' for several procedures.

03/23material

Procedure-specific Clarifications & Examples

Policy revisions clarified allowable procedures and listed conditions

Policy revisions clarified allowable procedures and listed conditions; conditions added or clarified are shown as examples to aid operational decision-making:

Procedure and condition clarifications

Examples of added/removed/clarified items: Removed one-anastomosis gastric bypass in Criteria III.L as duplicative; updated Criteria III.B to include other names of procedures for clarification; removed prior preoperative evaluation and medical clearance requirements in L.B. and L.C. and replaced with consolidated L.B.1 through L.B.3.
Conditions added or clarified: Added chronic kidney disease; added infertility; added polycystic ovarian syndrome; removed idiopathic intracranial hypertension as duplicative (pseudotumor cerebri retained); added heart failure; added unstable angina and recent MI within past 60 days to cardiovascular exclusions/considerations; updated nonalcoholic fatty liver disease/NASH verbiage.

Policy Summary

PayerCentene

PolicyClinical Policy: Bariatric Surgery

Policy CodePolicy CP .MP.37

Change TypeMultiple revisions (criteria, coding, preop consolidation, investigational wording)

Effective Date

Next Review Date

SourceLink

On This Page

Adolescent (<18 years)

BMI ≥ 40 kg/m2 or ≥ 140% of the 95th percentile (whichever is lower)
OR BMI ≥ 35 kg/m2 or ≥ 120% of the 95th percentile (whichever is lower) with at least one severe obesity-related comorbidity uncontrolled with lifestyle and pharmacotherapy
Severe comorbidities include type 2 diabetes mellitus, significant obstructive sleep apnea, idiopathic intracranial hypertension, severe NAFLD/NASH, slipped capital femoral epiphysis, Blount disease, severe GERD, hypertension; document failure of conservative management

Evidence of prior non-surgical weight loss attempts and failure: documented participation in and inadequate response to an organized weight management program (dietary, behavioral, and exercise interventions) and/or pharmacotherapy as appropriate, with documentation of duration and adherence

If pharmacotherapy was contraindicated or not appropriate, include explanation

Procedure appropriateness and selection

Requested procedure is appropriate for the patient’s BMI and comorbidity profile and is one of the covered procedures (e.g., LSG, RYGB, BPD-DS where indicated)
LAGB is considered only when consistent with age- and device-specific approvals and clinical guidance; note that LAGB is used less frequently in adolescents

Preoperative evaluation and medical clearance (within 6 months of scheduled surgery)

Comprehensive nutritional evaluation by a qualified provider (physician, PA, ARNP, or registered dietitian) with documentation of preoperative nutritional assessment and plan
Medical clearance by the primary care provider if no active cardiac or pulmonary comorbidities; cardiology and/or pulmonary clearance required when relevant conditions exist
Include any testing performed (e.g., ECG, stress testing, sleep study) and results
Age-appropriate psychological/psychiatric evaluation documenting that mental health conditions are identified and adequately managed and that the patient is a candidate for bariatric surgery
Documentation of informed consent discussion including risks, benefits, alternatives, and long-term follow-up requirements

Smoking cessation: patient is a non-smoker or has documented counseling and cessation plan; active tobacco use should be addressed preoperatively

Document status within 6 months of surgery

For adults of specific ethnicities, lower BMI thresholds may apply for indications (e.g., BMI ≥ 27.5 kg/m2 with comorbidity for some South Asian/East Asian populations) — document ethnicity and rationale

Repeat bariatric surgery — medical necessity

Repeat or conversion bariatric surgery is considered medically necessary when documentation meets ALL applicable criteria below:

ALL of the following

Indication for repeat or conversion surgery is specified and clinically justified (e.g., to correct complications such as obstruction, strictures, band erosion; to treat severe reflux after sleeve gastrectomy; or for inadequate weight loss/weight regain)
Timing and prior procedure requirements
- At least 24 months have elapsed since the index bariatric procedure for repeat procedures for inadequate weight loss or weight regain, unless there is a specific complication requiring earlier intervention (e.g., obstruction, erosion)
- If conversion is requested due to removal of an eroded adjustable gastric band, at least 2 months must have passed between band removal and the subsequent bariatric procedure
Failure-of-procedure criteria for inadequate weight loss/weight regain
- Documented weight loss from the initial procedure was less than 50% of the patient’s excess body weight at the time of the initial procedure
- Documented compliance with previously prescribed postoperative nutrition and exercise program, with supporting records
- Supportive documentation from the provider explaining why the initial procedure failed and clinical rationale for the proposed reoperative or conversion procedure
Allowed conversions and indications
- Conversion of sleeve gastrectomy (SG) to RYGB for treatment of severe GERD that has failed optimized anti-reflux medical therapy
- Conversion to RYGB or BPD-DS as clinically indicated (e.g., inadequate weight loss, metabolic indication) when documented rationale and risks are provided
All criteria listed for the initial bariatric procedure (age/BMI/comorbidity, preoperative evaluation and medical clearance) must be met again, unless the repeat surgery is solely to correct a complication that necessitates earlier intervention
Required documentation: operative reports of prior bariatric surgery, objective measures of current weight/BMI, records of prior postoperative follow-up and adherence, diagnostic studies relevant to the indication (e.g., endoscopy, imaging, sleep study, reflux testing), and a detailed clinical explanation for the need for repeat or conversion surgery

Policy-level requirement

Policy-level gating: ALL of the following policy-level requirements must be satisfied before considering coverage of bariatric surgery:

ALL of the following

I.A: Patient meets the age and BMI/comorbidity criteria as specified for initial bariatric surgery (adult or adolescent branches)
I.B: Required perioperative and pre-surgical assessments and medical clearances (nutritional, medical, and psychological/psychiatric) have been completed and documented within 6 months prior to the scheduled procedure

Consolidated preoperative evaluation and medical clearance requirements

Consolidated preoperative and medical-clearance requirements. These items (L.B.1–L.B.3) must be documented and are required for approval; see Operational/Provider Actions for specific documentation templates and timelines:

ALL of the following

Nutritional evaluation: documented assessment by a qualified provider (physician, PA, ARNP, or registered dietitian) including baseline nutritional status, deficiencies, and a preoperative nutrition plan
Medical clearance: PCP clearance if no active cardiac or pulmonary disease; cardiology and/or pulmonary clearance and any indicated testing (e.g., ECG, stress test, PFTs) when relevant comorbidities are present
Age-appropriate psychological/psychiatric consultation: evaluation stating the patient is an appropriate candidate for bariatric surgery and that mental health disorders are identified and adequately managed; include treatment plan if applicable
Linkage to Operational/Provider Actions: providers must supply the above documentation (evaluations, test results, clearance letters, and counseling records) with the prior authorization request; absence of complete documentation may result in denial or delay

LAP-BAND when BMI is 30 to 35 with or without comorbid conditions

Endoscopic suture revisions post bariatric surgery

Stomach aspiration therapy (e.g., AspireAssist)

Single anastomosis duodenoileal bypass (SADI)

Endoscopic gastrointestinal bypass devices (EGIBD)

Gastric plication / Endoluminal vertical gastroplasty

Endoscopic sleeve gastroplasty

Transoral endoscopic surgery

Gastric balloon devices (e.g., ReShape Duo, Orbera intragastric balloon, Obalon Balloon)

Gastric balloon (historic devices with safety concerns)

If due to eroded LAGB, at least ≥ 2 months between band removal and subsequent procedure

Weight loss from initial procedure < 50% of excess body weight

Documented compliance with prior postoperative nutrition and exercise program

Billing Rule

Use appropriate CPT/HCPCS codes

Report procedures using the CPT/HCPCS groups listed as supporting medical necessity and do not bill codes listed as not supporting medical necessity for covered indications.

CPT codes that support medical necessity (code group)
CPT codes that do NOT support medical necessity (code group)
HCPCS codes that support medical necessity (code group)
Do not bill codes listed as not supporting medical necessity

Documentation Required

Meet criteria sections I.A and I.B

Providers must document that all requirements in sections I.A and I.B are met prior to approval; the policy was corrected to require I.A and I.B to be satisfied.

Documentation Required

Preoperative consolidated requirements

Follow the consolidated preoperative evaluation and medical clearance requirements in L.B.1 through L.B.3 that replaced prior L.B. and L.C.; ensure documentation of required preoperative optimization steps before surgery.

Monthly nutritional counseling as required in L.B.4
GI screening and evaluation for clinically significant GI symptoms with documentation of treatment as required in L.B.9

Documentation Required

Monthly nutritional counseling

Document monthly nutritional counseling sessions as required by the updated Criterion L.B.4 prior to bariatric surgery.

Documentation Required

GI screening and treatment documentation

Document GI screening and evaluation for clinically significant GI symptoms and record any required treatment prior to bariatric surgery as specified in the updated Criterion L.B.9.

Professional positions: ASMBS and IFSO provide updated indications and cautious guidance for newer/variant procedures (eg, SADI-S) emphasizing need for long-term outcome data; NICE also encourages further research for some procedures and highlights recognized complications for specific operations.

Key evidence and guideline sources: the ASMBS guidance recommends metabolic and bariatric surgery for patients with BMI ≥ 35 kg/m2 regardless of comorbidity presence and recommends surgery for type 2 diabetes at BMI ≥ 30 kg/m2; ASMBS and IFSO joint indications and pediatric ASMBS guidance are referenced in the policy.

Randomized trial data: AspireAssist (percutaneous gastrostomy aspiration device) received FDA approval in 2016; a 2017 RCT (n=207) showed significantly greater weight loss with AspireAssist plus lifestyle counseling versus counseling alone (58.6% vs 15.3% achieved ≥25% excess weight loss at one year).

Other notable studies and reviews: the policy cites randomized and comparative studies relevant to investigational procedures (eg, Svanevik et al. RCT reporting perioperative outcomes for distal vs proximal gastric bypass in superobese patients), feasibility/series data on re-sleeve gastrectomy, RCTs on gastric imbrication, and systematic reviews/HTAs (Cochrane, Hayes) and multiple guideline/consensus documents (NICE, ASMBS pediatric and adult statements, AACE/ACE perioperative nutrition guidance).

Evidence gaps noted: for several procedures (mini/one-anastomosis gastric bypass, long/distal gastric bypass, endoscopic revisions, endoscopic sleeve gastroplasty, many balloon and endoluminal devices, SADI-S long-term outcomes) the policy states that current medical literature is inadequate to determine safety, efficacy and long-term outcomes and emphasizes need for further long-term randomized data.

Definitions

LSGLaparoscopic sleeve gastrectomy

LAGBLaparoscopic adjustable gastric banding

RYGBRoux-en-Y gastric bypass

BPD-DSBiliopancreatic diversion with duodenal switch

SADI-SSingle-anastomosis duodenoileal bypass with sleeve gastrectomy (single anastomosis duodenal switch)

Preoperative evaluations consolidated into L.B.1 through L.B.3:

Consolidated L.B.1-L.B.3: Meet consolidated requirements L.B.1 through L.B.3 as the preoperative evaluation and medical clearance standard; see operational/Provider Actions for required documentation.

Specific CPT codes 43290, 43291, 43632 were added to the not-supporting-medical-necessity list; other CPT code lists were added/removed across revisions.

04/25materialLatest

Corrected policy statement I to require requirements in I.A and I.B to be met instead of I.A-C, altering which sections must be satisfied for coverage decisions.

02/25material

Consolidated preoperative evaluation and medical clearance requirements into L.B.1 through L.B.3 replacing prior L.B. and L.C.

03/24material

Added chronic kidney disease, infertility, and polycystic ovarian syndrome to specified criteria lists; added heart failure and updated cardiovascular exclusions to include unstable angina and recent myocardial infarction (within 60 days).

undated (policy revision notes 03/24/2024 region)non-material

Procedure list cleaned up to avoid duplication by removing one-anastomosis gastric bypass in Criteria III.L.

10/20 to 03/24 (multiple entries)material

Operational preoperative screening requirement removed (I.B.10) — specifically removed requirement for Helicobacter pylori screening.

02/25material

Preoperative optimization updates: required monthly nutritional counseling (L.B.4) and GI screening/treatment documentation for clinically significant GI symptoms prior to surgery (L.B.9).