CurrentColorado Rocky Mountain Health PlansPolicy CS007OH.D

Bariatric Surgery (for Ohio Only)

Medical policy for bariatric and metabolic surgical and endoscopic interventions applicable to members in Ohio; defines use of InterQual criteria for medical necessity, lists unproven / not medically necessary procedures, applicable CPT/HCPCS codes for reference, definitions, and clinical evidence summaries.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBariatric Surgery (for Ohio Only)

Policy CodePolicy CS007OH.D

Change TypeRevised (procedural coverage language removed)Reference update

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionProviders must refer to and document InterQual CP: Procedures - Bariatric or Metabolic Surgery (adult) or Bariatric or Metabolic Surgery (Adolescent) when requesting bariatric/metabolic surgery to establish medical necessity.

SourceLink

POLICY UPDATE CHANGES

05/01/2025 - Removed language listing multiple bariatric surgical procedures as proven and medically necessary (including adjustable gastric band procedures, biliopancreatic diversion with duodenal switch, laparoscopic adjustable gastric band and revisions, revisional procedures, RYGB, sleeve gastrectomy, and removal of adjustable gastric band when not resulting in revisional surgery).

04/01/2026 - Updated reference link to reflect the current policy title for Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Ohio Only).

12+Named unproven procedures listed

40+CPT/Procedure codes listed (reference)

1State-specific applicability (Ohio only)

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PIVIIGB (Orbera) evidence threshold met

6.3%Reoperation rate

long-term RCTsResearch gap

Coverage Summary

This policy addresses bariatric and metabolic surgical and endoscopic interventions for members located in Ohio only, using InterQual CP: Procedures - Bariatric or Metabolic Surgery (adult and adolescent) as the referenced decision-support for medical necessity determinations. The policy is state-limited in applicability and notes that services listed as unproven or subject to coverage/quantity limits will be evaluated using Ohio Administrative Code 5160-101 when relevant.

The overall coverage stance reflects a mixed evidence base: established surgical procedures and devices are discussed alongside multiple procedures and devices that the policy identifies as unproven or not medically necessary due to insufficient evidence. The policy number is CS007OH.D and the effective date is 2025-05-01.

Key thresholds & quick-reference

Policy applicabilityApplies only to Ohio; medical necessity evaluated using InterQual and Ohio Administrative Code 5160-101

BMI thresholds (adult)MBS recommended ≥35 kg/m2; consider for 30–34.9 kg/m2 with metabolic disease; adjust for Asian ancestry (offer at ≥27.5 kg/m2)

Pediatric BMI thresholdsAAP/Endocrine: Class II ≥35 kg/m2 (or ≥120% of 95th percentile) with disease; Class III ≥40 kg/m2 (or ≥140% of 95th percentile); Endocrine Society: Tanner 4/5 and BMI >40 or >35 with major comorbidity

Intragastric balloon max placementMaximum placement time 6 months (e.g., ORBERA approved max 6 months)

PIVI TBWL thresholdASGE PIVI threshold: ≥5% total body weight loss for nonprimary bridge obesity therapy

Reoperation rateReoperations after bariatric operations: 6.3% (28,720 of 449,753); corrective 69.5%, conversions 30.5%

Proportion sleeve gastrectomySleeve gastrectomy is most commonly performed in US (~53.8% of bariatric procedures)

Medical-Necessity Criteria

General Medical Necessity Determination

Covered when ALL of the following are met. InterQual® CP: Procedures — Bariatric or Metabolic Surgery (adult) and Bariatric or Metabolic Surgery (Adolescent) should be used to assess medical necessity. This policy applies to Ohio; where InterQual criteria conflict with Ohio Administrative Code 5160-101, state requirements prevail.

ALL of the following

Documentation that InterQual CP criteria for Bariatric or Metabolic Surgery (adult) OR Bariatric or Metabolic Surgery (Adolescent) are satisfied. Note: use the adolescent criteria for members meeting pediatric/adolescent age definitions.
The procedure is intended to treat obesity (not as primary treatment for another non-obesity condition).
Preoperative Psychosocial and Nutritional Evaluation
- Preoperative psychosocial evaluation completed by a qualified behavioral health professional documenting assessment of mental health, substance use, eating disorder behaviors, readiness for surgery, understanding of risks/benefits, and availability of postoperative support.

Evidence Summary and Rationale

InterQual CP: Procedures - Bariatric or Metabolic Surgery (adult and adolescent) is specified as the primary clinical decision support used to determine medical necessity for bariatric and metabolic procedures.

The clinical evidence summarized in the policy is mixed to insufficient for many endoscopic and device-based therapies: many studies are small, single-arm or short-term, and long-term randomized data are frequently lacking. General study limitations cited include small sample sizes, loss to follow-up, selection bias, heterogeneous reporting, and short duration of follow-up.

The policy highlights that the Orbera intragastric balloon (IGB) meets the ASGE PIVI thresholds for efficacy (examples: %EWL and %TWL measures exceed PIVI thresholds) and thus is recognized as meeting that specific evidence benchmark; however, the policy also notes ongoing concerns about device tolerance, early removals, and uncertain long-term maintenance of weight loss after device removal. Across devices, the policy emphasizes the need for additional robust RCTs and longer-term outcome data.

Evidence-based conclusions by procedure/device

Summarized clinical evidence, limitations, and conclusions for each device/procedure as presented in the policy.

Aspiration Therapy (A-tube/AspireAssist): Multiple observational studies showing significant %EWL/%TWL at 1-4 years; limitations include small sample sizes, loss to follow-up, selection bias, and lack of long-term data after device removal.

Professional Society Recommendations

Professional society recommendations relevant to coverage decisions

Selected professional society recommendations and guideline points relevant to coverage decisions and clinical management.

ADA and international diabetes organizations: ADA and joint international diabetes organizations recommend metabolic surgery for specified BMI thresholds and emphasize adjustment by ancestry, long-term lifestyle support, and micronutrient monitoring.
ACG GERD guidance: ACG (GERD guideline 2022): Optimize PPI therapy for refractory GERD and recommend maintenance PPI or antireflux surgery for LA grade C/D esophagitis.
AGA on IGB: AGA (2021) recommends IGB plus lifestyle modification over lifestyle alone and peri-procedural measures including PPI prophylaxis and antiemetics; suggests against routine perioperative lab screening for nutritional deficiencies.

Revisional Surgery & Definitions

Revisional Bariatric Surgery

Definitions, reoperation rates and outcomes from ASMBS Revision Task Force and related society sources describing revisional bariatric surgery.

Definitions: Conversion: a second bariatric procedure that changes the approach to a different procedure; Corrective: a procedure to correct or modify anatomy to achieve the original desired outcome or address complications; Reversal: restores original anatomy.
Reoperation rates and breakdown: Data: of 449,753 bariatric operations, 28,720 (6.3%) underwent reoperations; 19,970 (69.5%) were corrective and 8,750 (30.5%) were conversions.
Weight loss outcomes after reoperation: Mean %EBWL after conversion: 39.3%; after corrective operation: 35.9%; primary operation %EBWL: 43.5%.

Coding and Device References

Provider Actions and Operational Requirements

Documentation Required

Use InterQual for Medical Necessity Determination

Use InterQual for Medical Necessity Determination. Refer to InterQual CP: Procedures — Bariatric or Metabolic Surgery (adult) and Bariatric or Metabolic Surgery (Adolescent) when requesting surgery. Document which InterQual version/criteria were used in the prior authorization request.

Documentation Required

State Rule Evaluation for Unproven/Quantity-Limited Services

State Rule Evaluation for Unproven/Quantity-Limited Services. Any service listed as unproven or quantity-limited in this policy will be evaluated for medical necessity using Ohio Administrative Code 5160-101. Include citation of OAC 5160-101 in the request if the service is unproven or limited.

Revision History

05/01/2025material

Removed language listing multiple bariatric surgical procedures as proven and medically necessary (including adjustable gastric band procedures, biliopancreatic diversion with duodenal switch, laparoscopic adjustable gastric band and revisions, revisional procedures, RYGB, sleeve gastrectomy, and removal of adjustable gastric band when not resulting in revisional surgery).

04/01/2026non-materialLatest

Updated reference link to reflect the current policy title for Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Ohio Only).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBariatric Surgery (for Ohio Only)

Policy CodePolicy CS007OH.D

Change TypeRevised (procedural coverage language removed)Reference update

Effective DateMay 1, 2025

Next Review DateN/A

SourceLink

On This Page

Documentation of treatment or stabilization plan for active psychiatric conditions (e.g., uncontrolled major depression, psychosis) when present; uncontrolled conditions must be addressed before surgery unless exception documented.

Assessment for disordered eating (including binge eating) with documentation of any treatment provided and determination that behaviors are controlled sufficiently for surgery to proceed.

Preoperative nutritional evaluation by a registered dietitian with documentation of nutrition history, dietary counseling, weight-loss attempt history, and a postoperative nutrition plan including vitamin/mineral supplementation strategy.

Evidence of participation in or documentation of referral to a multidisciplinary bariatric program (or equivalent) including surgeon, dietitian, and behavioral health as appropriate.

All required diagnostic testing, preoperative risk assessment, and informed consent documentation are present per InterQual and institutional standards.

Procedures Considered Unproven and Not Medically Necessary

The following procedures are considered unproven and not medically necessary for treating obesity.

ANY of the following

Bariatric surgery as the primary treatment for any condition other than obesity.
Bariatric artery embolization (BAE).
Gastric electrical stimulation with an implantable gastric stimulator (IGS).
Gastrointestinal liners.
Intragastric balloon.
Laparoscopic greater curvature plication (total gastric vertical plication).
Mini-gastric bypass (MGB)/laparoscopic mini-gastric bypass (LMGBP)/one-anastomosis gastric bypass (OAGB).
Single-anastomosis duodenal switch (duodenal switch with single anastomosis; SIPS).
Stomach aspiration therapy.
Transoral endoscopic surgery (includes TransPyloric Shuttle® (TPS®) device, endoscopic sleeve gastroplasty).
Vagus Nerve Blocking (VBLOC®).

Stomach Aspiration Study (Norén & Forssel 2016): Stomach Aspiration Therapy (Norén & Forssel 2016): Prospective observational study (n=25) with mean 54% excess weight loss at 1 year and 61% at 2 years; limitations include combination with CBT, no control group, unknown long-term patency.

Transoral Endoscopic / TPS: Transoral Endoscopic Surgery / Transpyloric Shuttle (TPS): Evidence limited; RCT inconclusive and case series high risk of bias; feasibility/single-arm trials report weight loss but lack of controls and long-term data.

Endoscopic Sleeve Gastroplasty (ESG): Endoscopic Sleeve Gastroplasty (ESG, OverStitch): Evidence insufficient/limited quality; systematic reviews and RCTs show ESG yields weight loss but generally less than laparoscopic sleeve gastrectomy (LSG); SAE rates low-moderate; need more RCTs and long-term outcomes.

Vagus Nerve Blocking (vBloc): Vagus Nerve Blocking (vBloc/Maestro): Mixed results — some trials show greater weight loss vs sham but pivotal ReCharge study did not meet prespecified co-primary efficacy endpoints; safety profile tolerable but longer-term durability uncertain.

Gastrointestinal Liner (EndoBarrier/DJBL): Insufficient evidence for routine use; RCTs and case series show weight loss and metabolic effects but high rates of adverse events (including liver abscess, GI hemorrhage), loss to follow-up, and weight regain after removal.

Intragastric Balloons (IGB/Orbera): ASGE/AGA reviews indicate Orbera meets PIVI thresholds and IGB with lifestyle modification is effective at short-term weight loss; concerns include device intolerance and early removal; long-term efficacy beyond 1 year uncertain.

General limitations across studies: small sample sizes, lack of randomized controlled data for many devices, short follow-up, selection bias, and variable definitions/reporting of adverse events.

Procedure-specific Evidence and Recommendations

Guideline and society positions that inform candidate selection, perioperative care, and procedural nuances for specific procedures.

ADA 2024: Metabolic surgery recommended for diabetes patients with BMI ≥ 30 (≥ 27.5 for Asian Americans) who are good surgical candidates; provide long-term lifestyle support and micronutrient monitoring.
Joint international diabetes organizations: Recommend metabolic surgery for Class III obesity (BMI ≥ 40) and Class II (BMI 35-39.9) with inadequately controlled hyperglycemia; consider for Class I with inadequate control; adjust BMI thresholds by ancestry.
ACG GERD guidance 2022: ACG (GERD guideline 2022): Optimize PPI therapy for refractory GERD and recommend long-term PPI or antireflux surgery for LA grade C/D esophagitis.
AGA on IGB (2021): AGA (2021) on IGB: Suggest IGB plus lifestyle modification over lifestyle alone; recommend moderate-high intensity lifestyle interventions, PPI prophylaxis, perioperative antiemetics, daily multivitamin supplementation, and against routine perioperative lab screening for nutritional deficiencies.
ASGE positions: ASGE: Orbera IGB meets PIVI thresholds; EBTs approved by FDA and meeting PIVI should be included as adjunctive therapies to lifestyle programs; recommend mechanisms for long-term follow-up care.
AACE/ASMBS guidance: AACE/Obesity Society/ASMBS guidance: BMI thresholds for bariatric surgery eligibility (≥40; ≥35 with comorbidities; consider 30-34.9 with T2DM), adjust for ethnicity, multidisciplinary evaluation, and comprehensive preoperative assessment; no evidence supports mandated preoperative weight loss as requirement.
ASMBS psychosocial: ASMBS presurgical psychosocial evaluation: Recommend involvement of behavioral health clinicians pre- and post-operatively and availability of postoperative psychosocial care.

Obesity is defined using Body Mass Index (BMI) (weight in kilograms divided by height in meters squared). Adult BMI categories cited include: Underweight <18.5; Normal 18.5–24.9; Overweight 25–29.9; Obesity Class I 30–34.9; Class II 35–39.9; Class III ≥ 40 kg/m2.

For adolescents, the ASMBS adolescent classifications are noted: Class II obesity defined as ≥120% of the 95th percentile or BMI 35–39.9 kg/m2 (whichever is lower) and Class III obesity defined as ≥140% of the 95th percentile or BMI ≥40 kg/m2 (whichever is lower). Growth charts and CDC BMI-for-age references are used for pediatric assessment.

A multidisciplinary bariatric team should include specialties such as a bariatric surgeon, obesity medicine specialist, registered dietitian, specialized nursing, behavioral health specialist, exercise specialist, and support groups; MBSAQIP accreditation and multidisciplinary assessment are emphasized for programs and revisional-surgery evaluation.

Common bariatric surgical procedures described include: Roux-en-Y gastric bypass (RYGB) (creation of a small stomach pouch and bypass of stomach/duodenum), laparoscopic adjustable gastric banding (LAGB) (inflatable silicone band around proximal stomach), vertical sleeve gastrectomy (VSG/SG) (resection of ~60–75% of stomach creating a tubular sleeve), and biliopancreatic diversion with duodenal switch (BPD/DS) (malabsorptive operation with a short common channel).

Revisional bariatric surgery is defined and subclassified: a conversion changes the index procedure to a different bariatric operation (not an intraoperative conversion), a corrective procedure addresses complications or incomplete treatment effect without changing the initial operation, and a reversal restores original anatomy. The policy references MBSAQIP processes and the need for thorough multidisciplinary reassessment prior to revisional procedures.

Robotic-assisted surgery is noted as an available technique that can offer three-dimensional vision and increased dexterity for precision dissection, and transoral/endoscopic approaches (NOTES and transoral restorative techniques) are described as investigational or evolving approaches under study.

Endoscopic therapies covered in background include: Endoscopic Sleeve Gastroplasty (ESG) using an endoscopic suturing system (e.g., OverStitch) to reduce gastric capacity, TransPyloric Shuttle (TPS) (a space-occupying, tethered device approved for up to 12 months in specified BMI ranges), intragastric balloons (IGBs) (acid-resistant balloons filled with saline or air, typically maximum placement six months), gastrointestinal liners (EndoBarrier/DJBL), stomach aspiration therapy (AspireAssist), bariatric artery embolization (BAE), and gastric electrical stimulation (GES/CLGES) and vagus nerve blocking (VBLOC) neuromodulation. Many of these endoscopic and device therapies are noted as under investigation with variable evidence quality.

ASGE PIVI and EBTs: ASGE: Endoscopic bariatric therapies that meet FDA approval and ASGE/ASMBS PIVI thresholds (e.g., Orbera) should be included as adjunctive therapies to lifestyle programs; require mechanisms for long-term follow-up.

AACE/ASMBS selection guidance: AACE/Obesity Society/ASMBS: BMI thresholds and multidisciplinary evaluation described; selection individualized to goals, local expertise, and comorbidities; no mandated preoperative weight loss requirement.

Indications for Metabolic and Bariatric Surgery (society summaries)

Society statements summarizing indications for metabolic and bariatric surgery across adult and pediatric populations.

ASMBS/IFSO: MBS recommended for individuals with BMI ≥ 35 kg/m2 regardless of comorbidities; consider for BMI 30–34.9 kg/m2 with metabolic disease; adjust thresholds for Asian populations (offer MBS at BMI ≥ 27.5 kg/m2).
NICE: Offer bariatric surgery for BMI ≥ 40 kg/m2, or BMI 35–39.9 kg/m2 with a significant health condition likely to improve with weight loss; expedite for BMI ≥ 35 or 30–34.9 with recent-onset (≤10 years) T2DM assessed in specialist weight management.
AAP (pediatrics): AAP: Recommend MBS for patients >12 years with Class II obesity (BMI ≥ 35 or ≥120% of 95th percentile) with clinically significant disease, or Class III obesity (BMI ≥ 40 or ≥140% of 95th percentile).
Endocrine Society (pediatrics): Endocrine Society: Suggest bariatric surgery only when Tanner 4/5 and final or near-final height and BMI > 40 kg/m2 or BMI > 35 kg/m2 with significant comorbidities (T2DM, moderate-severe OSA, pseudotumor cerebri, advanced NASH, debilitating orthopedic problems).
VA/DoD: Suggest offering MBS for adults with BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with obesity-associated conditions; suggest offering option for patients with BMI ≥ 30 kg/m2 and T2DM.

Society recommendations for adolescents

Society recommendations for adolescents and pediatric-specific selection and care requirements.

Multicomponent individualized approach involving metabolic/bariatric team, patient, and guardians; referral to comprehensive center experienced with <18-year-old patients.
Holistic evaluation: Evaluation should include holistic view of patient and family, including psychosocial and social risk factors.
Preoperative attempts at diet/exercise should not be a barrier; compliance with multidisciplinary program may improve outcomes.
Transition planning: Adolescents should have access to transition plan to adult MBS program for lifelong care.

Clinical implications: Restorative operations for intolerable side effects (e.g., band removal) may result in weight gain and return of comorbidities; reoperation complication rates are higher than primary but overall low; careful patient selection recommended.

Body Mass Index (BMI): A person's weight in kilograms divided by the square of height in meters.

Multidisciplinary: A bariatric center or regimen combining several disciplines (bariatric surgeon, obesity medicine specialist, registered dietician, specialized nursing, behavioral health, exercise specialist, support groups).

Obstructive Sleep Apnea (OSA) severity: Mild AHI/RDI ≥5 and <15; Moderate ≥15 and ≤30; Severe >30/hour.

Revisional Bariatric Surgery - Conversion: A second bariatric procedure that changes the approach from one procedure to a different type (not an intraoperative conversion).

Revisional Bariatric Surgery - Corrective: Procedure that corrects or modifies anatomy of a previous bariatric procedure to achieve original desired outcome or correct a complication.

Revisional Bariatric Surgery - Reversal: A procedure that restores original anatomy.

EWL: Excess weight loss (abbreviated).

TBWL / TWL: Total body weight loss / total weight loss (abbreviated).

IGB: Intragastric balloon (abbreviated).

GES / CLGES: Gastric electrical stimulation / closed-loop gastric electrical stimulation (abbreviated).

ESG: Endoscopic Sleeve Gastroplasty (abbreviated).

DJBL: Duodenal-Jejunal Bypass Liner (EndoBarrier) (abbreviated).

InterQual: A proprietary clinical decision support criteria set used by UnitedHealthcare for medical/surgical determinations.

ASAM: American Society of Addiction Medicine; used by UnitedHealthcare for substance use criteria.

Billing Rule

Coding Clarification for Sleeve Gastrectomy

Coding Clarification for Sleeve Gastrectomy. Use CPT code 43775 to report laparoscopic sleeve gastrectomy instead of the unlisted CPT code 43659. Ensure claims and prior authorization requests reference the correct code to avoid denials or miscoding.

Affected CPT codes: 43775, 43659

Documentation Required

Evidence limitations and informed consent

Evidence limitations and informed consent. Document device-specific risks, limitations of long-term efficacy (including likelihood of weight regain), and that the member received counseling on alternative therapies. For devices/procedures deemed unproven (e.g., intragastric balloons, endoscopic sleeve gastroplasty), document that informed consent included discussion of limited evidence and potential need for repeat or adjunctive therapies.

Documentation Required

Multidisciplinary preoperative evaluation

Multidisciplinary preoperative evaluation. Document a comprehensive preoperative assessment including: medical history and comorbidities, targeted laboratory testing, behavioral health evaluation, nutritional assessment by a registered dietitian, and documentation of prior weight loss attempts including duration and adherence to medically supervised programs.

Required elements: history and comorbidities, pertinent labs, behavioral health assessment, registered dietitian evaluation, prior weight loss attempts and outcomes

Prior Authorization

Long-term follow-up plan

Long-term follow-up plan. Provide mechanisms for enrollment and documentation of long-term follow-up per professional guidance (e.g., ASMBS/ASGE). Prior authorization should include the proposed follow-up plan (clinic visits, nutrition and behavioral health follow-up) and how follow-up data will be documented and reported.

Billing Rule

Perioperative prophylaxis for IGB

Perioperative prophylaxis for intragastric balloons (IGB). Code and document prophylactic perioperative measures as appropriate; ensure billing aligns with applicable CPT/HCPCS/E/M codes and facility billing guidance.

Consider associated endoscopy CPT codes (e.g., 43290, 43291, 0813T) when billing for IGB placement, removal, or adjustment

Documentation Required

Preoperative psychosocial and nutritional evaluations

Preoperative psychosocial and nutritional evaluations. Document completion of preoperative psychosocial assessment and nutritional counseling by qualified providers. Records should include screening for psychiatric conditions, substance use, eating disorders, adherence potential, and a documented nutrition plan with goals prior to surgery or device implantation.

Documentation Required

Multidisciplinary program referral for adolescents

Multidisciplinary program referral for adolescents. For adolescent candidates, refer to or document evaluation by a pediatric or adolescent-focused multidisciplinary metabolic/bariatric surgery center. Include pediatric growth charts/BMI percentiles, maturational assessment, and involvement of pediatric specialists as part of the evaluation.

Documentation Required

Informed consent and follow-up for intragastric balloons

Informed consent and follow-up for intragastric balloons (IGB). Obtain device-specific informed consent that includes potential complications, need for removal/replacement, limited long-term durability, and plan for ongoing nutrition and behavioral follow-up. Document scheduled removal dates and contingency plans for complications.

Documentation Required

Consider relative contraindications

Consider relative contraindications. Document assessment of relative contraindications (e.g., significant psychiatric disease, active substance use disorder, inability to adhere to follow-up, pregnancy/planning pregnancy, certain prior abdominal surgeries) and rationale if proceeding despite relative contraindications.

Note

Reference and regulatory alignment

Reference and regulatory alignment. Ensure all requests align with this Ohio-only policy, InterQual criteria, and OAC 5160-101. Cite these references in the prior authorization and document how the member meets referenced criteria or why an exception is requested.