ModifiedColorado Rocky Mountain Health PlansPolicy SRST2026T0362RR

Bariatric Surgery

Defines medical necessity, covered and not medically necessary bariatric surgical procedures, candidate eligibility criteria for adults, adolescents, two-stage and revisional procedures, and applicable billing codes for Colorado Rocky Mountain Health Plans members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBariatric Surgery

Policy CodePolicy SRST2026T0362RR

Change TypeMaterial revisions to criteria, added MD-specific COMAR language, coding updates

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and verify member-specific benefits; document BMI, preoperative evaluation, and required COMAR diet/psychological documentation when applicable.

SourceLink

POLICY UPDATE CHANGES

Replaced references to 'Nonalcoholic Fatty Live Disease (NAFLD)' with 'Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)'.

Revised coverage criteria for a planned two-stage procedure and replaced 'compliant with nutrition and exercise' with 'adherent to nutrition and exercise'.

Added unproven/not medically necessary procedures: Silastic ring vertical gastric bypass and transoral endoscopic surgery including transoral outlet reduction (TORe).

Replaced wording grouping 'gastrointestinal liners' and 'intragastric balloon' under 'transoral endoscopic surgery including ...'.

Removed CPT code 64999 from Applicable Codes.

Added specific criteria language for fully insured group policies in Maryland per COMAR, including BMI thresholds, age, psychological examination, and structured diet program completion details.

Updated supporting sections: Description of Services, Clinical Evidence, FDA, and References; removed Medical Records Documentation Used for Reviews section; archived previous policy version 2026T0362QQ.

4+procedures proven/necessary

BMI 35–39.9

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adult eligibility w/ comorbidity

BMI ≥40adult primary threshold

12–17adolescent group

≤2 yrstwo-stage timing

Mostplans excluding bariatric

Coverage Criteria and Clinical Determinations

Initial adult bariatric surgery medical necessity

Covered when ALL of the following are met

Adult age and procedure: Individual aged ≥18 years undergoing one of the listed procedures (biliopancreatic diversion/BPD-DS, gastric bypass including robotic-assisted, adjustable gastric banding [for individuals ≥18 years], or sleeve gastrectomy).age ≥18

See procedure list and age requirement

BMI criteria: Either BMI ≥ 40 kg/m2 (or BMI ≥ 37.5 kg/m2 in individuals of Asian descent) OR BMI 35.0–39.9 kg/m2 (or 32.5–37.4 kg/m2 Asian) in the presence of one or more qualifying comorbidities (insulin resistance/type 2 diabetes; cardiovascular disease including poorly controlled hypertension despite pharmacotherapy, coronary artery disease; history of cardiomyopathy; obstructive sleep apnea confirmed on polysomnography with AHI/RDI ≥ 30; evidence of Metabolic Dysfunction-Associated Steatotic Liver Disease [MASLD]; idiopathic intracranial hypertension).see BMI thresholds

Comorbidities listed in policy

Preoperative evaluation: Completion of preoperative evaluation including detailed weight history, dietary and physical activity patterns, and either a psychosocial-behavioral evaluation by a professionally recognized behavioral health provider OR participation in a multidisciplinary surgical preparatory regimen.preop evaluation documented

Documentation required per policy

Adolescent bariatric surgery medical necessity

Covered when ALL of the following are met

Age: Individual aged 12–17 years.age 12–17

Adolescent age range per policy

Adolescent BMI/comorbidity: Either Class III obesity OR Class II obesity with at least one qualifying comorbidity (insulin resistance/type 2 diabetes; poorly controlled hypertension despite pharmacotherapy; hyperlipidemia; obstructive sleep apnea confirmed on polysomnography with AHI/RDI ≥ 30; evidence of MASLD; idiopathic intracranial hypertension).see BMI charts and definitions

Comorbidities and class definitions per policy and CDC growth/BMI charts

Multidisciplinary center evaluation: Evaluation at or in consultation with a multidisciplinary center focused on surgical treatment of severe childhood obesity (e.g., MBSAQIP-accredited adolescent centers or equivalent).

Planned two-stage bariatric surgery

Covered when ALL of the following are met

Initial BMI ≥ 50 kg/m2 prior to first-stage bariatric procedure.BMI ≥50 kg/m2

Two-stage initial BMI requirement

Timing: Second-stage definitive bariatric procedure occurs within 2 years following the primary bariatric surgery.second stage within 2 years

Timing requirement per policy

Adherence: Individual has been adherent to nutrition and exercise as documented in the medical record.adherence documented

Adherence required before second stage

Revisional bariatric surgery

Revisional procedures are covered when due to a technical failure or major complication

Indications for revisional surgery: Conversion, corrective, or reversal procedures when performed for technical failure or major complication of the index bariatric operation (examples include bowel perforation, adjustable gastric band erosion, adjustable gastric band migration/slippage uncorrectable by manipulation/adjustment, leak, obstruction confirmed by imaging, staple-line failure, mechanical adjustable gastric band failure).complication documented

See list of potential failures/complications

Uncontrollable reflux after sleeve gastrectomy: For persistent reflux after sleeve gastrectomy, revisional surgery is covered only when all of the following are documented: maximum nonpharmacological management has failed (positional/dietary/behavioral measures); maximum pharmacological management has failed (at least 1 month of double-dose PPI, H2 blocker, and/or sucralfate); and severe esophagitis (Grade C or D) confirmed by endoscopy despite maximal medical management.treatment failure and Grade C/D esophagitis

Specific reflux criteria required before revisional intervention

Unproven / not medically necessary procedures

The following are unproven and not medically necessary due to insufficient evidence of efficacy

Unproven / not medically necessary procedures: Bariatric artery embolization; gastric electrical stimulation with an implantable gastric stimulator; laparoscopic greater curvature plication (LGCP); mini-gastric/one-anastomosis gastric bypass (OAGB/MGB); silastic ring vertical gastric bypass (SRVGB); single-anastomosis duodenal switch (SADI-S/SADS); transoral endoscopic surgery including endoscopic sleeve gastroplasty (OverStitch), gastrointestinal liners (e.g., EndoBarrier/DJBL), intragastric balloons, transoral outlet reduction (TORe); TransPyloric Shuttle device; and other procedures listed in the policy considered investigational or lacking sufficient long-term RCT evidence.not covered/investigational

Procedures listed as unproven or investigational in policy

Maryland (COMAR) surgical eligibility

For Fully Insured Group Policies in Maryland: covered when ALL of the following COMAR-specified criteria are met

COMAR BMI and comorbidity: One of the following BMI criteria: BMI > 40 kg/m2 without co-morbidity OR BMI ≥ 35 kg/m2 with one or more obesity-related comorbid medical conditions (hypertension, cardiopulmonary condition, sleep apnea, diabetes, or any life‑threatening/serious weight‑induced medical condition).see COMAR BMI thresholds

COMAR §31.10.33.03B requirements

Age requirement: Age 18 years or older.age ≥18

COMAR age threshold

Psychological evaluation: Completion of a psychological examination documenting readiness and fitness for surgery and necessary postoperative lifestyle changes.psych exam documented

Clinical evidence summaries (no explicit medical necessity criteria in this excerpt)

Evidence summaries and comparative outcomes (no explicit authorization decision rules in this section).

Comparative effectiveness summaries: Randomized and long-term comparative data indicate RYGB generally yields greater long-term weight loss, higher T2D remission rates, and greater GERD improvement versus sleeve gastrectomy, though sleeve gastrectomy has fewer late major complications in some analyses.

Supported by RCT meta-analyses

Long-term durability: Systematic reviews report substantial long-term excess weight loss with RYGB and BPD/DS at ≥10 years; LAGB demonstrates inferior long-term durability with high rates of band removal/revision in multiple cohorts.

Long-term cohort and systematic review findings

Safety considerations: Procedure-specific complication profiles differ (e.g., internal hernia after RYGB; staple-line leaks and esophagitis after sleeve gastrectomy; nutritional deficiencies after BPD/DS), and surgical technique or modality (robotic vs laparoscopic) may affect early reoperation rates in pooled studies.

Adverse event data across trials and cohorts

Procedure-specific coverage conclusions

Coverage stance and evidence notes by procedure:

Laparoscopic Adjustable Gastric Banding (LAGB): Long-term observational studies show modest weight-loss durability with notable rates of band removal, revision, and conversion; outcomes are generally less favorable than other bariatric operations and should be weighed when authorizing LAGB.examples: long-term cohorts showing high band removal rates

See long-term LAGB cohort data

Adolescent Bariatric Surgery: Registry and prospective data demonstrate substantial BMI and glycemic improvements after RYGB or sleeve gastrectomy in adolescents, with low short-term complication rates in large series; authorization should document age, BMI, comorbidities, and multidisciplinary assessment.document age/BMI/comorbidities/center evaluation

Supported by Teen-LABS and registry analyses

Bariatric Artery Embolization:

Coverage stance for less-established bariatric procedures

Evidence-based coverage stance for the procedures summarized in this section

General evidence requirement: Procedures with limited high-quality long-term evidence (e.g., LGCP, OAGB/MGB, SRVGB, SADI-S/SADS) should be considered investigational or covered only with documented rationale and robust long-term follow-up plans until RCTs with long-term outcomes are available.evidence insufficiency

Reflects repeated policy conclusions

LGCP-specific: LGCP demonstrates inferior and less durable weight loss with notable revision rates; not preferred as primary bariatric surgery based on current evidence.

Meta-analysis and cohort evidence

OAGB/MGB-specific: OAGB/MGB may yield weight-loss outcomes comparable to RYGB in the short to mid term but has higher reported rates of de novo GERD and marginal ulcers; coverage decisions should weigh GERD risk and require counseling and monitoring.

Systematic reviews report higher GERD/marginal ulcer rates

Coverage considerations and evidence-driven criteria

Coverage considerations based on available evidence summaries

SADI-S/SADS: Current evidence consists largely of small RCTs and observational cohorts with short-to-medium follow-up; consider SADI-S/SADS investigational or conditional pending larger long-term comparative studies, and require documentation of nutritional follow-up plans if considered for coverage.evidence gap and follow-up plan

Missing long-term data and nutritional concerns

Endoscopic Sleeve Gastroplasty (ESG): ESG demonstrates greater short-term weight loss than lifestyle modification but less than surgical sleeve gastrectomy; safety signals include procedure-related SAEs and registry-reported readmissions/reoperations; consider ESG with documented patient selection (BMI criteria, prior nonsurgical therapy) and informed consent about limited long-term durability.limited long-term data

Randomized trials and systematic reviews referenced

Gastrointestinal Liner (DJBL/EndoBarrier):

Candidate selection and BMI thresholds

Guideline-recommended candidacy and perioperative considerations (professional society recommendations):

General bariatric candidacy per major societies: Patients with BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with at least one severe obesity-related comorbidity are candidates for bariatric/metabolic surgery; consider patients with BMI 30.0–34.9 kg/m2 who have metabolic disease (e.g., T2D) according to some guidelines; adjust BMI thresholds for ethnicity (lower thresholds for Asian patients).BMI thresholds per society

AACE/ASMBS/IFSO guideline positions

IGB therapy — recommended use and perioperative care

Professional society recommendations regarding intragastric balloons (IGBs):

IGB use conditions: IGB therapy is suggested for patients who have failed conventional weight-loss strategies and should be combined with moderate- to high-intensity lifestyle modification; prophylactic PPI therapy is recommended; daily multivitamin supplementation is suggested; and perioperative antiemetic strategies and structured follow-up are advised.device-specific recommendations

AGA and ASGE positions summarized

Transoral outlet reduction — effectiveness and safety thresholds

ASGE PIVI performance thresholds for transoral outlet reduction:

Transoral outlet reduction thresholds met: Transoral outlet reduction (TORe) meets ASGE PIVI thresholds when pooled total weight loss (TWL) ≥ 5% and pooled SAE rate ≤ 5%; subgroup analysis shows pursestring suture pattern achieves greater TWL (12.8%) and pooled SAE rate ~1.5%, meeting PIVI thresholds and supporting clinical adoption for recurrent weight gain after RYGB.TWL >=5% and SAE <=5%

ASGE systematic review results

General candidate selection and preoperative requirements

Coverage and candidate selection should follow guideline BMI and comorbidity thresholds and multidisciplinary evaluation.

Adult MBS candidacy and preoperative requirements: Patients should meet BMI/comorbidity thresholds per contemporary guidelines (e.g., ASMBS/IFSO) and undergo multidisciplinary evaluation including nutritional and behavioral assessment prior to surgery; adjust BMI thresholds for ethnicity as recommended by societies.see guideline thresholds

ASMBS/IFSO and AACE positions

Pediatric/adolescent MBS candidacy: For patients <18 years, follow AAP/Endocrine/ASMBS guidance: consider MBS for adolescents meeting Class II or III obesity definitions with relevant comorbidities, require Tanner stage/physiologic maturity assessment, family/psychosocial evaluation, and referral to experienced pediatric MBS centers with multidisciplinary long-term follow-up capacity.see pediatric thresholds

AAP and Endocrine Society recommendations

Revisional bariatric surgery

Revisional/Reoperative surgery coverage considerations

Indications and selection for reoperation: Reoperative bariatric surgery may be considered for insufficient weight loss, persistent comorbid disease, complications, or intolerable side effects after multidisciplinary evaluation; selection should account for prior procedure, anatomy, weight/comorbidities, and surgeon experience.multidisciplinary evaluation documented

ASMBS Revision Task Force guidance

Nutritional risk after distalization: Distalization procedures that shorten the common channel to < 200 cm or result in total alimentary limb length (TALL) < 400 cm carry a high risk of severe macro- and micronutrient deficiencies and require aggressive supplementation and close longitudinal monitoring.CC <200 cm; TALL <400 cm

ASMBS limb-length safety guidance

Endoscopic/device therapies

Endoscopic and device-based therapies coverage considerations

Intragastric balloon (IGB): IGB therapy can produce notable short-term weight loss and is FDA‑cleared for temporary use (maximum ~6 months for some devices); safe deployment requires multidisciplinary program involvement, informed consent about device-specific AEs, and plans for post‑removal long‑term weight management.maximum placement per device labeling

ASMBS and FDA device information

Endoscopic sleeve gastroplasty (ESG): ESG may be considered for selected patients (class I/II obesity or select class III individuals not candidates for surgery) with documentation of prior nonsurgical therapy failure and informed consent about limited long-term data; reported SAE rate approx 1.25% in pooled analyses.SAE rate ~1.25% reported

IFSO systematic review

Guideline-based coverage considerations

Guideline-based considerations for offering bariatric surgery or endoscopic interventions

NICE surgical candidacy: NICE recommends offering bariatric surgery for adults with BMI ≥ 40 kg/m2 or BMI 35.0–39.9 kg/m2 with a significant health condition likely to improve with weight loss, and considers expedited surgery for recent-onset T2D at lower BMI thresholds; NICE also suggests lower BMI thresholds for specified ethnic groups (reduce by 2.5 kg/m2).see NICE thresholds

NICE 2025 guidance

OSA and surgical referral considerations: AASM recommends discussing referral to bariatric surgery for adults with class II/III obesity (BMI ≥35 kg/m2) who are intolerant of PAP; consider referral for certain adults with BMI <40 intolerant of PAP in selected circumstances.AASM thresholds apply

AASM task force recommendations

VA/DoD suggestions: VA/DoD guidance suggests offering MBS for patients with BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with obesity-associated conditions and suggests IGBs for patients with BMI ≥ 30 kg/m2 prioritizing short-term weight loss (up to 6 months), in conjunction with lifestyle intervention.

Procedures limited to research or special governance

Interventional procedures with limited evidence where guidance restricts use

DJBL / EndoBarrier: NICE and other assessments state that gastrointestinal liners (e.g., EndoBarrier/DJBL) have limited evidence and should only be used in research contexts or under special arrangements with detailed patient selection and follow-up reporting.research or special governance

NICE IPG and device status

SADI-S/SADS: NICE/IFSO note limited quantity and quality of evidence for SADI-S/SADS and recommend use only with special arrangements for governance, consent, audit, or research and encourage registry participation and long-term follow-up.special arrangements required

Guidance recommends research governance

Maryland COMAR bariatric surgery coverage criteria (fully insured groups)

For fully insured group policies in Maryland, use the following COMAR-specified criteria

COMAR MD bariatric surgery criteria: ALL of the following: BMI > 40 kg/m2 without co-morbidity OR BMI ≥ 35 kg/m2 with at least one obesity-related comorbid medical condition; age ≥18 years; completion of a psychological examination documenting readiness and fitness for surgery and postoperative lifestyle changes; AND completion of a structured diet program defined as either one structured program for six consecutive months OR two structured programs for three consecutive months within the two-year period immediately preceding the request. Documentation of structured diet completion may include physician notes, other provider notes, receipts, or diet/weight-loss logs.as stated in COMAR

Applies to fully insured group policies in Maryland per COMAR §§31.10.33.03B/04

Bariatric surgery performed as the primary treatment for any condition other than obesity is excluded from coverage. This policy scope is limited to interventions intended to treat obesity and its direct sequelae; procedures whose primary indication is a non‑obesity condition do not meet coverage criteria.

Providers and authorization reviewers should note that most benefit plans exclude coverage for bariatric surgery. Before initiating authorization or scheduling procedures, verify member‑specific benefits because exclusion of bariatric surgery in a member’s plan may result in denial of coverage.

Gastrointestinal liners such as the EndoBarrier are considered investigational for routine use in the United States and are not FDA‑approved; per federal law these devices are limited to investigational use only. As such, EndoBarrier and similar duodenal‑jejunal bypass liners are excluded from routine coverage outside of approved research or special governance arrangements.

The policy identifies a set of procedures considered unproven or not medically necessary based on insufficient high‑quality, long‑term evidence. The updated list now explicitly includes silastic ring vertical gastric bypass and transoral endoscopic surgery, including transoral outlet reduction (TORe). These procedures — along with other listed interventions such as bariatric artery embolization, gastric electrical stimulation, laparoscopic greater curvature plication, and certain device treatments — are managed as investigational or not medically necessary for routine coverage.

Applicable Billing Codes and Key Thresholds

Applicable CPT/temporary codes (part 1)CPT

0813T	Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon.
43290	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon.
43291	Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s).
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.
43647	Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum.
43648	Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum.
43659	Unlisted laparoscopy procedure, stomach.
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.

1–10 of 12

1/2

Applicable CPT/temporary codes (part 2)CPT

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).
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).
43846	Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy.
43847	Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption.
43848	Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure).
43860	Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy.
43865	Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy.
43881	Implantation or replacement of gastric neurostimulator electrodes, antrum, open.

Applicable CPT/temporary codes (part 3)CPT

43882	Revision or removal of gastric neurostimulator electrodes, antrum, open.
43886	Gastric restrictive procedure, open; revision of subcutaneous port component only.
43887	Gastric restrictive procedure, open; removal of subcutaneous port component only.
43888	Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only.
43889	Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG), including argon plasma coagulation, when performed.
43999	Unlisted procedure, stomach.
64590	Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver.
64595	Revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array.

Removed CPT CodesCPT

64999

CPT code 64999 removed from Applicable Codes

Procedures discussed (no explicit codes listed in this section)mixed

No codes listed

Device approvals and regulatory referencesmixed

Orbera IGB PMA P140008 / P140008S016	Orbera Intragastric Balloon System — FDA PMA references; indicated BMI ≥30 and ≤40 kg/m2, max 6 months placement.
LAP-BAND System (various PMA references)	Adjustable gastric banding — FDA approved labeling; indicated for adults with BMI ≥40 or ≥35 with comorbidity; adjustable bands contraindicated in patients <18 years.
OverStitch K181141	OverStitch Endoscopic Suturing System — 510(k) approved for endoscopic suturing and tissue approximation.
TransPyloric Shuttle P180024a	TransPyloric Shuttle — PMA indicated for BMI 35.0–40.0 or 30.0–34.9 with comorbidity.
EndoBarrier (investigational)	Duodenal-jejunal bypass liner — investigational; previously had IDE and no current CE mark per NICE; limited evidence—use in research contexts.

inv-50: Body Mass Index (BMI) — Adults and two-stage thresholds

Adult BMI primary eligibilityAdults: BMI ≥ 40 kg/m2 (or ≥ 37.5 kg/m2 for individuals of Asian descent)

Adult BMI with comorbidityAdults: BMI 35–39.9 kg/m2 (or 32.5–37.4 kg/m2 for individuals of Asian descent) plus ≥1 qualifying comorbidity (e.g., T2D, poorly controlled hypertension, CAD, OSA with AHI/RDI ≥30, MASLD, idiopathic intracranial hypertension)

Two‑stage initial BMI requirementFor planned two‑stage procedures, initial BMI ≥ 50 kg/m2 prior to first‑stage surgery

Adolescent BMI classes referencedAdolescents: use Class II/Class III definitions per pediatric guidance (see adolescent criteria)

Prior Authorization, Documentation, and Operational Guidance

Prior Authorization

Prior Authorization and Benefit Verification

Prior authorization requirements vary by member plan. Providers must verify member-specific benefits and whether prior authorization is required before scheduling procedures; use carrier portals or third-party tools as available. Where prior authorization is required, include procedure type, patient age, baseline BMI, comorbidities, and relevant preoperative evaluations in the submission.

Prior authorization is implied only when benefits exist — many benefit plans exclude bariatric surgery; check the member’s benefit plan document.
When required, prior authorization submissions should capture: procedure type, patient age, baseline BMI, obesity-related comorbidities, and presurgical evaluations (nutritional and psychosocial).

Documentation Required

Eligibility: BMI and Comorbidity Documentation

Eligibility for bariatric procedures is determined by BMI thresholds and documented comorbidities per the policy and applicable guidelines. Procedures may be denied if adult or adolescent BMI and comorbidity criteria are not met.

Background and Scope

Bariatric surgery is intended to produce substantial, durable weight loss to reduce obesity‑related comorbidities and improve quality of life. Procedures fall into restrictive, malabsorptive, or combined categories and are selected based on patient BMI, comorbidities, and multidisciplinary assessment. First‑line care remains structured medical management (diet, physical activity, behavioral therapy, and medications); bariatric procedures are covered only when patients meet the policy’s defined eligibility criteria and when benefit coverage exists.

Definitions and Terminology

inv-110: Asian — definition and examples

Geographic/ancestral definitionAsian: refers to origins from the Far East, Southeast Asia, or the Indian subcontinent (e.g., Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippines, Thailand, Vietnam)

Implication for BMIAsian ancestry triggers lower BMI thresholds used elsewhere in the policy (see Asian‑adjusted BMI thresholds)

Source referenceDefinition adapted from U.S. Census Bureau (2012)

inv-111: Body Mass Index — definition and use

BMI definitionBody Mass Index (BMI) = weight in kilograms divided by the square of height in meters

Screening roleBMI is used as a screening tool with class ranges (underweight, normal, overweight, obesity classes I–III)

Policy Revisions and Effective Dates

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBariatric Surgery

Policy CodePolicy SRST2026T0362RR

Change TypeMaterial revisions to criteria, added MD-specific COMAR language, coding updates

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and verify member-specific benefits; document BMI, preoperative evaluation, and required COMAR diet/psychological documentation when applicable.

SourceLink

On This Page

center evaluation documented

Refer to adolescent program accreditation guidance

Ongoing medical necessity at second stage: Individual meets applicable medical necessity criteria at the time of the second-stage procedure.criteria met at second stage

Reassess BMI/comorbidities and other criteria at time of second stage

Psych exam required per COMAR

Structured diet program completion: Completion of a structured diet program as defined (either one structured program for six consecutive months OR two structured programs for three consecutive months within the two-year period immediately preceding the request); documentation may include physician notes, other health care provider notes, receipts, or diet/weight-loss logs.structured diet program documented

Acceptable documentation per COMAR §31.10.33.04

Evidence is limited to small trials and case series with modest short-term weight loss and incomplete safety characterization; procedure remains investigational and typically noncovered outside research contexts.

Small RCTs and heterogeneous studies

Gastric Electrical Stimulation (GES): Early feasibility studies report variable weight-loss signals; high-quality RCT evidence with long-term follow-up is lacking and GES is considered investigational.evidence gap

Small feasibility studies reported

Laparoscopic Greater Curvature Plication (LGCP): Comparative data show inferior and less durable weight loss versus established procedures and nontrivial revision rates; LGCP is considered investigational or lower-preference pending stronger comparative data.inferior durability and revision risk

Meta-analyses and single-center cohorts cited

SRVGB-specific: SRVGB shows some mid-term weight-loss benefit vs RYGB in limited studies but introduces device-specific late complications and variable techniques; treat as investigational/limited pending higher-quality evidence.

HTA and limited RCT evidence

SADI-S/SADS-specific: SADI-S/SADS shows superior short-term weight loss in some trials but carries concerns about malabsorption, diarrhea, and incomplete long-term safety data; if covered, require documented plan for intensive nutritional monitoring and management.nutritional monitoring plan required

RCTs and cohort data note higher malabsorption risk

DJBL provides short-term weight and glycemic improvements while in situ but has high early removal (~19%) and SAE (~17%) rates; routine coverage is not supported outside research or tightly governed programs with safety monitoring.

high adverse event rate

Pooled meta-analysis results

Intragastric Balloons (IGB): IGBs produce short-term clinically significant weight loss but most patients regain weight after removal; device-specific evidence is mixed and associated with early intolerance and AEs; use may be limited to temporary bridge-to-surgery or structured programs with plans for post-removal long-term weight management.temporary benefit, limited durability

ECRI and society assessments

Preoperative psychosocial and nutritional evaluation:

Presurgical psychosocial evaluation by behavioral health clinicians and preoperative nutritional screening/education are expected to identify risks and establish perioperative support and monitoring plans.

psychosocial and nutrition documentation

ASMBS presurgical evaluation recommendations

VA/DOD 2020 guideline

inv-51: Adolescent age range and class — Adolescents aged 12–17 eligibility

Age rangeAdolescents aged 12–17 years

Eligibility by obesity classClass III obesity OR Class II obesity with ≥1 qualifying comorbidity (insulin resistance/T2D, poorly controlled hypertension, hyperlipidemia, OSA with AHI/RDI ≥30, MASLD, idiopathic intracranial hypertension)

Multidisciplinary evaluationEvaluation at or in consultation with a multidisciplinary center focused on surgical treatment of severe childhood obesity (e.g., MBSAQIP‑accredited adolescent centers) is required

inv-52: Two-stage timing — Second stage must occur within 2 years of primary surgery

Timing for second stageSecond stage must occur within 2 years following the primary bariatric surgery procedure

Initial BMI requirementInitial BMI must be ≥ 50 kg/m2 prior to the first‑stage procedure

Adherence requirementIndividual must have been adherent to nutrition and exercise prior to second stage

inv-53: BMI thresholds (COMAR - Maryland fully insured group policies)

COMAR BMI — no comorbidityBMI above 40 kg/m2 without co-morbidity

COMAR BMI — with comorbidityBMI ≥ 35 kg/m2 with one or more obesity‑related comorbid medical conditions (hypertension, cardiopulmonary condition, sleep apnea, diabetes, or other weight‑induced life‑threatening/serious condition)

ApplicabilityApplies to fully insured group policies in Maryland per COMAR §31.10.33.03B

inv-54: Age threshold (COMAR)

Minimum age (COMAR)Age 18 years or older

Policy applicabilityRequired for fully insured group policies in Maryland per COMAR

Documentation requirementPsychological examination of readiness and fitness for surgery is required (see COMAR)

inv-55: Structured diet program timing (COMAR)

Structured diet program windowCompletion in the 2‑year period immediately preceding request

Option A — single programOne structured diet program for six consecutive months meets the requirement

Option B — two programsTwo structured diet programs for three consecutive months each meet the requirement

Acceptable documentationPhysician notes, other health care provider notes, receipts of payment, or diet/weight‑loss logs may document completion

inv-56: BMI thresholds for MBS — guideline-aligned thresholds and Asian adjustments

Guideline BMI thresholds (adults)ASMBS/IFSO: MBS recommended at BMI ≥ 35 kg/m2; consider for BMI 30–34.9 kg/m2 with metabolic disease

Asian‑adjusted thresholdsLower BMI thresholds for Asian individuals: clinical obesity suggested at BMI ≥ 25 kg/m2 and consider MBS at BMI ≥ 27.5 kg/m2

Device‑specific ranges referencedSome devices (e.g., Orbera) have FDA‑labeled BMI ranges (see device approvals)

inv-57: Common channel safety threshold — lengths associated with high risk of severe nutritional deficiencies

Common channel safety thresholdCommon channel length < 200 cm associated with high risk of severe macro‑ and micronutrient deficiencies after distalization

Total alimentary limb length (TALL) cautionTotal alimentary limb length (AL + CC) < 400 cm also associated with high nutritional risk

Monitoring implicationPatients undergoing distalization require aggressive supplementation and regular nutrition monitoring

inv-58: Device-specific BMI indications (Orbera, LAP-BAND, TransPyloric Shuttle)

Orbera (IGB) FDA indicationOrbera indicated for adults with BMI ≥ 30 and ≤ 40 kg/m2; maximum placement period 6 months

LAP‑BAND indicationLAP‑BAND indicated for adults with BMI ≥ 40 kg/m2 or ≥ 35 kg/m2 with comorbidity; adjustable bands contraindicated <18 years

TransPyloric Shuttle indicationTransPyloric Shuttle indicated for BMI 35.0–40.0 kg/m2 or 30.0–34.9 kg/m2 with comorbidity (PMA)

inv-59: BMI criteria (Maryland COMAR) — restatement

Maryland COMAR BMI restatementFor fully insured group policies in Maryland: BMI > 40 kg/m2 without co‑morbidity OR BMI ≥ 35 kg/m2 with obesity‑related co‑morbid conditions

Required ancillary criteriaAge ≥ 18, psychological exam documenting readiness/fitness, and structured diet program completion per COMAR

Documentation examplesPhysician notes, other provider notes, receipts, or diet/weight‑loss logs may document structured diet completion

Adults: e.g., BMI ≥ 40 kg/m2 (or adjusted lower thresholds for Asian adults) or BMI ≥ 35–39.9 kg/m2 with qualifying comorbidities.
Adolescents: follow pediatric guideline thresholds and require multidisciplinary evaluation or accredited adolescent MBS center consultation.

Denial Risk

Revisional Surgery — Documentation Expectations

Revisional surgery must be justified with documentation of technical failure, major complication, or clinically significant weight-regain. Lack of adequate documentation of the need for revision may lead to denial.

Common indications: bowel perforation, band erosion or migration not correctable by adjustment, leak, obstruction (imaging-confirmed), staple-line failure, mechanical band failure, or severe reflux after sleeve gastrectomy satisfying maximal medical management criteria.
Document attempts at nonoperative correction (e.g., band manipulation/adjustment) and prior interventions when applicable.

Denial Risk

Investigational Procedures and Evidence Limitations

Many less-established or investigational procedures have limited, low-quality, or short-term evidence — small sample sizes, single-center designs, variable techniques, and incomplete long-term follow-up are common limitations. These evidence gaps can lead to prior authorization denials or require enrollment in clinical studies.

Policy may classify procedures as unproven/not medically necessary when evidence of efficacy or safety is insufficient.
When evidence limitations exist, require submission of supporting literature, rationale for expected benefit, and a plan for long-term follow-up if seeking coverage.

Denial Risk

Procedure-Specific Evidence Concerns (LGCP, OAGB, Transoral Endoscopic, DJBL)

Specific procedure-level evidence concerns that affect coverage and authorization decisions should be documented and considered in medical necessity determinations.

LGCP: evidence shows inferior and less durable weight loss versus established procedures and higher revision rates — expect scrutiny and likely denial absent strong justification.
OAGB/MGB: limited long-term data and signals of higher rates of de novo GERD and marginal ulcers compared with RYGB; document GERD risk and rationale if selecting OAGB.
Transoral endoscopic procedures: limited long-term safety and efficacy data; may be considered investigational without robust RCTs.
DJBL (EndoBarrier): safety concerns — high early removal and SAE rates (device migration, GI hemorrhage, obstruction, hepatic abscess); document safety monitoring and rationale for use.

Denial Risk

Evidence Limitations May Trigger Coverage Denial or Additional Requirements

Insufficient or conflicting evidence, high rates of device removal or serious adverse events, and significant loss to follow-up in studies may be grounds for noncoverage. Providers should present robust supporting data when requesting coverage for these interventions.

Examples: DJBL demonstrated substantial early removal and SAE rates; long-term benefit after explantation is unclear.
Endoscopic procedures (ESG, IGBs) have mixed evidence — short-term weight loss is often seen but durability and long-term safety are uncertain.

Documentation Required

Nutritional Monitoring and Follow-up Requirements

Nutritional risks and the need for ongoing monitoring must be documented. Failure to provide appropriate nutritional screening and postprocedure follow-up can lead to unmanaged deficiencies and adverse outcomes.

Preoperative nutritional assessment and education should be documented.
Postprocedure plans must include scheduled nutritional monitoring, vitamin/mineral supplementation as indicated, and arrangements for long-term follow-up with a registered dietitian or WLS program.

Denial Risk

Contraindications per Endocrine Society and Related Guidance

Adhere to guideline contraindications: do not perform bariatric surgery in preadolescent children, pregnant or breastfeeding adolescents (or those planning pregnancy within 2 years), or patients who have not demonstrated mastery of healthy dietary/activity habits or have unresolved substance use, active eating disorders, or untreated psychiatric conditions.

Ensure psychosocial and behavioral evaluations are completed and documented by qualified behavioral health clinicians prior to authorization submissions.
Document any contraindications identified and management plans when applicable.

Note

References and Role in Authorization

This section summarizes references and guidance sources that inform clinical and coverage considerations. It does not independently establish authorization or denial criteria — those decisions rest on documented medical necessity, member benefits, and applicable mandates.

The policy cites multiple professional society guidelines, systematic reviews, HTAs, and FDA device information to support clinical context.
Providers should reference cited literature when submitting complex or investigational requests.

Step Therapy

Step Therapy and Plan-Level Constraints

No plan-level step therapy requirements for bariatric procedures are specified in this policy excerpt. Step-therapy or other utilization management requirements are determined by the member’s specific benefit plan and any applicable state or federal mandates.

Before elective scheduling, verify whether the member’s benefit plan imposes any step therapy, preauthorization, or exclusion for bariatric services.

Adult BMI class cutpointsObesity Class I 30–34.9; Class II 35–39.9; Class III ≥ 40 kg/m2

inv-112: Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) — definition

MASLD definitionHepatic steatosis by imaging or histology without other cause plus metabolic criteria (e.g., BMI ≥25 [≥23 Asia], elevated glucose/A1c, hypertension, triglycerides, low HDL)

Diagnostic elementsIncludes steatosis plus one or more cardiometabolic risk factors (glucose abnormalities, BP ≥130/85 or treatment, triglycerides ≥150 mg/dL or treatment, low HDL or treatment)

ReferenceRinella et al., 2023

inv-113: Revisional Bariatric Surgery — definitions for conversion/corrective/reversal

Conversion definitionConversion: a second bariatric procedure that changes the bariatric approach to a different procedure type (not intraoperative approach change)

Corrective definitionCorrective: a procedure that corrects or modifies anatomy of a prior bariatric operation to achieve the original desired outcome or correct a complication

Reversal definitionReversal: a procedure that restores original anatomy

inv-114: Restrictive procedures — definition

Restrictive procedure conceptProcedures intended to cause weight loss by reducing stomach size to limit food intake

Examples implicationIncludes procedures that reduce gastric capacity (e.g., VSG, LAGB, some endoscopic therapies)

Mechanism noteMay reduce appetite and intake; may be performed laparoscopically or open

inv-115: Malabsorptive procedures — definition

Malabsorptive procedure conceptProcedures intended to cause weight loss by limiting nutrient absorption in the intestines

ExamplesIncludes BPD/DS and variations that bypass portions of small intestine leading to malabsorption

RisksAssociated with higher risk of long‑term nutritional deficiencies requiring monitoring and supplementation

inv-116: Vertical sleeve gastrectomy (VSG) — definition

VSG descriptionVertical sleeve gastrectomy: surgical removal of ~60–75% of the stomach creating a narrow gastric sleeve; reduces capacity and ghrelin production

Physiologic noteNot purely malabsorptive; lifetime nutritional supplementation typically not required

UseCan be standalone or part of staged approaches

inv-117: Roux-en-Y gastric bypass (RYGB) — definition

RYGB descriptionRoux‑en‑Y gastric bypass: creation of a small stomach pouch attached to the small intestine, bypassing most of the stomach and duodenum

MechanismCombines restrictive and malabsorptive elements depending on limb lengths

ConsiderationsAssociated with internal hernia, strictures, and nutritional implications depending on reconstruction

inv-118: EWL / TWL / Excess BMI loss — metric definitions

EWL definitionEWL = excess weight loss (percentage of weight lost relative to excess above ideal)

TWL definitionTWL = total weight loss (percentage of total body weight lost)

Excess BMI lossExcess BMI loss = change in BMI relative to excess above normal — used in trials and long‑term studies

inv-119: BPD/DS — definition and notes

BPD/DS definitionBiliopancreatic diversion with duodenal switch: a malabsorptive bariatric procedure associated with high long‑term diabetes remission but notable nutritional deficiencies

Long‑term outcomesHigh rates of diabetes remission reported but significant long‑term nutritional monitoring required

Risk noteNutritional problems common (reported ~29.8% in one long‑term series)

inv-120: LAGB — definition and long-term outcome notes

LAGB definitionLaparoscopic adjustable gastric banding: restrictive procedure using an adjustable band placed around the proximal stomach

Long‑term outcome noteLong‑term observational studies show variable durability and substantial rates of band removal, revision, or conversion

Age contraindicationAdjustable gastric bands contraindicated in patients younger than 18 years (FDA labeling)

inv-121: Bariatric artery embolization — definition and evidence status

Bariatric artery embolization conceptEndovascular embolization targeting gastric arteries (e.g., left gastric artery) intended to induce weight loss

Evidence statusEvidence limited to small RCTs and case series; considered investigational pending larger controlled studies

Safety concernsSafety profile not fully characterized for elective obesity indication

inv-122: Gastric electrical stimulation (GES/CLGES) — definition and evidence status

GES/CLGES definitionGastric electrical stimulation: implantable devices intended to modulate gastric activity and appetite

Evidence statusEarly feasibility studies show mixed weight‑loss signals; high‑quality long‑term RCT evidence lacking; considered investigational

Reported outcomesSmall studies report variable EWL and limited metabolic effects compared with other bariatric procedures

inv-123: LGCP / LGGCP — definition and evidence concerns

LGCP / LGGCP definitionLaparoscopic greater curvature plication: imbrication of greater curvature to reduce gastric volume without resection or staples

Evidence concernsComparative data show inferior and less durable weight loss vs established procedures and notable revision rates

Coverage stanceConsidered investigational/limited pending stronger comparative long‑term data

inv-124: Laparoscopic Greater Curvature Plication (LGCP) — definition

LGCP procedureA restrictive procedure that imbricates the greater curvature to reduce gastric volume without resection or staple line

Clinical outcome noteAssociated with weight regain and revision in some series; long‑term efficacy uncertain

RecommendationRequires more robust RCTs and long‑term follow‑up

inv-125: OAGB/MGB — definition and risk notes

OAGB/MGB descriptionOne‑Anastomosis/mini‑gastric bypass: single‑anastomosis bypass producing weight loss comparable to RYGB in some trials

Risk noteReported higher rates of de novo GERD and marginal ulcers compared with RYGB; requires counseling and monitoring

Evidence statusLong‑term comparative RCT data limited; additional trials encouraged

inv-126: Silastic Ring Vertical Gastric Bypass (SRVGB) — definition

SRVGB definitionSilastic ring vertical gastric bypass: RYGB with placement of a silastic ring to maintain stoma restriction

Outcome noteMay improve medium‑term weight maintenance but introduces device‑specific late complications and variable techniques

Evidence statusRandomized evidence limited; technique and device reporting need standardization

inv-127: SADI-S/SADS — definition and evidence notes

SADI‑S/SADS definitionSingle‑anastomosis duodeno‑ileal switch: sleeve gastrectomy combined with single duodeno‑ileal anastomosis producing hypoabsorptive effect

Evidence notesShows superior short‑term weight loss vs RYGB in some trials but raises concerns about malabsorption and frequent nutritional deficiencies; long‑term high‑quality evidence limited

Governance recommendationIFSO/NICE recommend registry participation, long‑term follow‑up and use with special arrangements until more data available

inv-129: ESG (Endoscopic Sleeve Gastroplasty) — definition and outcomes

ESG definitionEndoscopic sleeve gastroplasty: transoral endoscopic suturing (OverStitch) to reduce gastric volume

OutcomesReported mean TBWL ~15–17% at 6–24 months; SAE rate reported ~1.25% in pooled analyses

Evidence statusObservational evidence of low quality; limited long‑term (>5 yr) outcomes; recommended for select patients with informed consent

inv-130: DJBL (EndoBarrier) — definition and safety concerns

DJBL/EndoBarrier definitionDuodenal‑jejunal bypass liner: endoscopic gastrointestinal liner creating proximal small‑intestine barrier

Safety concernsHigh pooled early removal rate (~19%) and SAE incidence (~17%) including hepatic abscess and GI hemorrhage

Coverage stanceConsidered investigational/limited to research contexts pending stronger safety and long‑term efficacy data

inv-131: IGB (Intragastric Balloon) — definition and evidence

IGB definitionIntragastric balloon: temporary intragastric device (fluid‑ or gas‑filled; swallowable or endoscopically placed) to induce short‑term weight loss

Durability noteProduces short‑term clinically significant weight loss but weight regain is common after removal

Device‑specific evidenceOrbera indicated for BMI 30–40 kg/m2 with max 6‑month placement; evidence for long‑term benefit inconclusive

inv-132: Dual intragastric balloon (DBS) — definition and trial evidence

Dual IGB (DBS) definitionDual intragastric balloon system: two balloons placed endoscopically to occupy gastric volume and promote weight loss

Trial evidenceREDUCE pivotal trial (n=326) showed greater TBWL at 32 weeks vs diet/exercise alone; additional RCTs with longer follow‑up needed

Device risksReported balloon deflation ~6% and early retrieval for intolerance ~9% in trials

inv-133: TransPyloric Shuttle — definition and evidence

TransPyloric Shuttle definitionEndoscopic device designed to delay gastric emptying by intermittently occluding the pylorus

Evidence statusEvidence limited and inconclusive; trials small and short‑term; further controlled studies required

FDA indicationPMA indicates use for BMI 35.0–40.0 or 30.0–34.9 with comorbidity (see FDA section)

inv-134: Reoperative surgery — definition and categorization

Reoperative surgery definitionAny operation after the first bariatric operation that counted toward center‑of‑excellence volume requirements; includes corrective procedures and conversions

SubcategoriesCorrective (address complication or incomplete effect) vs conversion (change index operation) vs reversal (restore anatomy)

Selection noteReoperations pose higher risk than primary procedures and require multidisciplinary evaluation

inv-135: Common bariatric procedures — list of common procedures mentioned

Common procedures listCommon bariatric procedures referenced: sleeve gastrectomy, RYGB, BPD/DS, SADI‑S, OAGB, adjustable gastric banding, ESG, IGB, and reoperative procedures

ContextReferenced across guideline and evidence sections as established or evolving options

inv-136: SADI-S/SADS — definition (additional)

SADI‑S/SADS succinct definitionSingle‑anastomosis duodeno‑ileal bypass with sleeve (SADI‑S) / Single‑anastomosis duodeno‑ileostomy with sleeve (SADS): simplified duodenal switch variant combining sleeve gastrectomy with single anastomosis

Evidence notePromising short‑to‑mid‑term weight loss and T2D control but frequent nutritional deficiencies and limited long‑term high‑quality evidence

inv-137: ESG — definition (additional)

ESG (additional)Endoscopic sleeve gastroplasty uses OverStitch endoscopic suturing; pooled analyses report TBWL ~15–17% at 6–24 months and SAE rate ~1.25%

Evidence qualityMajority observational; only limited RCT data; long‑term durability beyond 5 years uncertain

inv-138: Professional organizations referenced — ASMBS, IFSO, AGA, NICE, ECRI, Hayes

Professional organizations referencedASMBS, IFSO, AGA, NICE, ECRI, Hayes (among others) cited for guideline and technology assessment guidance

RoleSources used for recommendations on candidacy, device guidance, and evidence synthesis

inv-139: MASLD terminology update — Replaced NAFLD with MASLD in policy text

Terminology updatePolicy replaced 'Nonalcoholic Fatty Liver Disease (NAFLD)' with 'Metabolic Dysfunction‑Associated Steatotic Liver Disease (MASLD)'

LocationChange documented in Policy History/Revision Information (05/01/2026)