Clinical Policy: Bariatric Surgery
Defines medical necessity, coverage criteria, investigational and not medically necessary bariatric surgical procedures and preoperative requirements for members of Centene-affiliated Health Net plans; applies to adult and adolescent candidates. Covers indications, repeat/revisional surgery, investigational techniques, and excluded procedures.
Single-anastomosis duodenoileal bypass (SADI)/SADI-S was added to the Description and to medically necessary criteria and removed from investigational procedures.
BMI thresholds and indications were updated, including thresholds for South Asian, Southeast Asian, and East Asian adults, and Type 2 diabetes moved to an absolute co-morbidity.
Contraindications were consolidated and expanded to include severe cardiac disease prohibitive for anesthesia and untreated eating disorders, among others.
One-anastomosis gastric bypass was removed from a criteria list as duplicative; LAP-BAND criterion for BMI 30-35 was removed.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.