Modifiedhusky_healthPolicy N/A

Primary Bariatric Surgery – Coverage Criteria and Prior Authorization

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Governs prior authorization, medical necessity criteria, and coverage considerations for primary bariatric surgical procedures for HUSKY Health (Connecticut Medicaid) members aged 18 and older; intended for providers requesting authorization. InterQual is used when available; this policy applies when InterQual criteria are not available.

Policy Summary

Payerhusky_health

PolicyPrimary Bariatric Surgery – Coverage Criteria and Prior Authorization

Policy CodePolicy N/A

Change TypeMaterial updates and clarifications (coding, investigational list, clinical guidance)

Effective DateNov 1, 2024

Last ReviewSep 16, 2025

Next Review DateN/A

Key ActionSubmit a fully completed authorization request via the online portal with documentation supporting medical necessity, including evidence of supervised weight loss program participation when applicable.

SourceLink

POLICY UPDATE CHANGES

Clarified nutritional counseling requirement in the Clinical Guideline section.

Added ASMBS endorsed procedures reviewed using policy to criteria.

Clarified notation on reviews for individuals under the age of 18.

Removed intragastric balloon and one anastomosis gastric bypass (mini gastric) from the investigational list to include endoscopic procedures.

Removed codes 43647, 43648, 43881, 64590, and 64595 from the list of codes reviewed using policy as they do not require prior authorization.

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Modifiedhusky_healthPolicy N/A

Primary Bariatric Surgery – Coverage Criteria and Prior Authorization

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Policy Summary

Payerhusky_health

PolicyPrimary Bariatric Surgery – Coverage Criteria and Prior Authorization

Policy CodePolicy N/A

Change TypeMaterial updates and clarifications (coding, investigational list, clinical guidance)

Effective DateNov 1, 2024

Last ReviewSep 16, 2025

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

Clarified nutritional counseling requirement in the Clinical Guideline section.

Added ASMBS endorsed procedures reviewed using policy to criteria.

Clarified notation on reviews for individuals under the age of 18.

Removed intragastric balloon and one anastomosis gastric bypass (mini gastric) from the investigational list to include endoscopic procedures.

Removed codes 43647, 43648, 43881, 64590, and 64595 from the list of codes reviewed using policy as they do not require prior authorization.

2024-11-01policy effective date

BMI ≥35coverage BMI threshold

BMI 30-35lower BMI branch

Prior auth requiredPA required

18+min age

Medical Necessity & Coverage Criteria

Primary bariatric surgery — medical necessity criteria

Covered when ALL of the following are met

Age: Individual is 18 years of age or older>=18 years

Policy does not address procedures for individuals <18 (those are reviewed using InterQual)

BMI criteria

Lower BMI branch requirements: Type 2 diabetes or metabolic syndrome AND documented history of participation in a supervised weight loss program AND inability to achieve or maintain weight loss AND inadequate control of hyperglycemia

Procedure-specific and behavioral conditions: Procedure must be an allowed primary procedure (examples listed include Single Anastomosis Duodeno-ileostomy with Sleeve [SADI-S] or Intragastric Balloon) AND all of the following: documentation of compliance with behavioral and dietary modifications to promote postoperative weight loss; no substance or alcohol use disorder by history or substance/alcohol free for at least one year; no uncontrolled psychiatric condition with psychosocial evaluation and clearance by behavioral health provider; no tobacco use by history or tobacco-free for at least six weeks prior to surgery; completed dietary and/or nutrition consultation confirming clearance and expected compliance; individual verbalizes understanding of procedure and importance of post-procedure compliance; planned follow-up care with health care team; not currently pregnant and no plans for pregnancy within 18 months of surgery; no significant GI symptoms or, if present, documented clearance from a physician experienced in GI conditions; endocrine causes of obesity ruled out by history, exam, or labs; and the procedure is not investigationalsee text

Many pre-operative clearance and compliance requirements listed

The policy designates vertical banded gastroplasty (CPT 43842) as not medically necessary. This determination is based on the procedure no longer being on the American Society of Metabolic and Bariatric Surgery (ASMBS) endorsed procedures list and aligns with the policy position that procedures not endorsed by ASMBS are investigational or not medically necessary for treatment of obesity.

The publication history was updated to clarify why vertical banded gastroplasty (VBG) is not covered; specifically, VBG is no longer ASMBS‑endorsed and therefore is considered not medically necessary under this policy.

The policy lists procedures that are not endorsed by the ASMBS and therefore considered investigational and not medically necessary for obesity treatment. Items explicitly included are: bariatric artery embolization (BAE); endoscopic gastrointestinal bypass devices; gastric electric stimulation with implantable gastric stimulator; laparoscopic greater curvature plication (described by CPT 43843); open gastric banding; single anastomosis duodenal switch; stomach aspiration therapy; endoscopic gastric remodeling procedures (e.g., Overstitch/ESG/POSE/Endomina/TORe); transpyloric shuttle; vagus nerve blocking; and use of gastrointestinal liners.

The investigational list was revised in recent updates. Notably, the publication history documents removal of intragastric balloon and one‑anastomosis gastric bypass (mini gastric) from the investigational list, reflecting changes to the policy’s investigational procedure considerations.

Coding and BMI Thresholds

Codes that may be used to request and bill for primary bariatric surgery (non-exhaustive)CPT

43290	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon.
43291	Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s).
43659	Unlisted laparoscopy procedure, stomach.
43842	Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty.
43843	Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty.
43999	Unlisted procedure, stomach.
44799	Unlisted procedure, small intestine.

Codes removed from PA review listCPT

43647	code removed from list reviewed using policy
43648	code removed from list reviewed using policy
43881	code removed from list reviewed using policy
64590	code removed from list reviewed using policy
64595	code removed from list reviewed using policy

inv-08: BMI thresholds — coverage thresholds including adjusted thresholds for Asian descent and criteria when T2DM/metabolic syndrome present

Primary BMI thresholdBMI ≥35 (≥32.5 if of Asian descent) with documented history of participation in a supervised weight loss program and inability to achieve or maintain weight loss

Lower BMI branch for metabolic diseaseBMI 30–35 (27.5–32.5 if of Asian descent) with all of: (1) Type 2 diabetes or metabolic syndrome; (2) documented participation in a supervised weight loss program; (3) inability to achieve or maintain weight loss; and (4) inadequate control of hyperglycemia

Supervised weight loss requirementDocumented history of participation in a supervised weight loss program with inability to achieve or maintain weight loss is required for BMI-based eligibility

Asian descent adjustmentsThresholds reduced by 2.5 BMI points for individuals of Asian descent (≥32.5 instead of ≥35; 27.5–32.5 instead of 30–35)

Authorization, Documentation & Provider Resources

Prior Authorization

Prior authorization required for primary bariatric surgery

Prior authorization is required for primary bariatric surgery. Use the listed CPT codes to request authorization when InterQual criteria do not apply.

Codes that may be used to request authorization include: 43290, 43291, 43659, 43842, 43843, 43999, 44799.

Billing Rule

PA code updates — specific CPTs removed

Codes 43647, 43648, 43881, 64590, and 64595 have been removed from the list of codes reviewed using this policy because they do not require prior authorization; providers must still verify PA requirements via the Benefit and Authorization Grids.

Background

Bariatric surgical procedures address obesity and related conditions using restrictive and/or malabsorptive techniques. Common interventions include Roux‑en‑Y gastric bypass, sleeve gastrectomy, adjustable gastric banding, and biliopancreatic diversion with duodenal switch. This policy uses InterQual criteria when available and provides coverage criteria for primary bariatric procedures when InterQual guidance is not applicable.

Definitions

inv-18: Medically Necessary or Medical Necessity — statutory definition per CT General Statutes § 17b-259b

Statutory definition sourceDefined per Connecticut General Statutes § 17b-259b

Scope of servicesHealth services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate an individual's medical condition, including mental illness

Standards for determinationServices must be consistent with generally accepted standards of medical practice (credible peer‑reviewed evidence, specialty society recommendations, views of practicing physicians, and other relevant factors)

Clinical appropriateness and costServices must be clinically appropriate in type, frequency, timing, site, extent and duration, not primarily for convenience, and not more costly than an alternative providing equivalent results

Individualized assessmentDetermination must be based on an assessment of the individual and their medical condition

Publication & Revision History

2025-09-23approvalLatest

Policy approved by DSS following updates that removed specific codes from the PA list and updated investigational list to include endoscopic procedures; operational clarifications and additions were recorded.

2025-09-16committee_approval

Approved by the CHNCT Clinical Quality Subcommittee after clarifications to nutritional counseling, notation for individuals under 18, addition of ASMBS-endorsed procedures to criteria, and updates to investigational procedures.

2025-08-27

Policy Summary

Payerhusky_health

PolicyPrimary Bariatric Surgery – Coverage Criteria and Prior Authorization

Policy CodePolicy N/A

Change TypeMaterial updates and clarifications (coding, investigational list, clinical guidance)

Effective DateNov 1, 2024

Last ReviewSep 16, 2025

Next Review DateN/A

SourceLink

On This Page

Removed codes: 43647, 43648, 43881, 64590, 64595.

Documentation Required

Document participation in supervised weight loss program

A documented history of participation in a supervised weight loss program with inability to achieve or maintain weight loss is required for BMI-based eligibility.

Required for BMI ≥35 (≥32.5 if of Asian descent) branch and for BMI 30–35 (27.5–32.5 if of Asian descent) branch per criteria.

Prior Authorization

Submit a fully completed authorization request

Complete the authorization request fully — incomplete or missing required information will prevent review of the bariatric surgery request.

Ensure all fields on the online authorization form are completed and include supporting documentation from the requesting physician.

Prior Authorization

Authorization request must be submitted online with supporting documentation

Submit a fully completed authorization request via the online web portal and include documentation from the requesting physician that supports medical necessity for review.

Use the on-line web portal for authorization submission.
Attach physician documentation demonstrating medical necessity per policy criteria.

Note

Where to verify prior authorization requirements

Check the Benefit and Authorization Grids on www.ct.gov/husky and the CMAP provider fee schedules and regulations at www.ctdssmap.com to determine if a service requires prior authorization and for definitive benefit and service limitations.

Navigate to 'For Providers' then 'Benefit Grids' on www.ct.gov/husky for summaries.
Use www.ctdssmap.com for CMAP provider fee schedules and regulations.

Denial Risk

Risk of denial if medical necessity documentation is insufficient

Prior authorization is required; if documentation at the time of authorization does not meet medical necessity criteria, the request may be denied.

Provide complete case-specific information and supporting documentation to demonstrate medical necessity at time of authorization.

Denial Risk

Authorization is contingent on medical necessity and active coverage

Authorization decisions are based on medical necessity at the time the authorization is issued and do not guarantee payment — payment depends on the member having active coverage, applicable benefits, and policies in effect at the time of service.

Authorization is not a payment guarantee; verify active coverage and benefits at time of service.

inv-19: HUSKY Health Program — definition and programs included

Programs includedThe HUSKY Health Program comprises HUSKY A, HUSKY B, HUSKY C, HUSKY D and HUSKY Limited Benefit programs

HUSKY A descriptionConnecticut children and their parents or a relative caregiver; pregnant women may qualify; income limits apply

HUSKY B descriptionUninsured children under 19 in higher income households (Children's Health Insurance Program); family cost-sharing may apply

HUSKY C descriptionConnecticut residents age 65+ or ages 18–64 who are blind or have another disability (includes MED‑Connect); income and asset limits apply

HUSKY D descriptionConnecticut residents ages 19–64 without dependent children who do not qualify for HUSKY A, do not receive Medicare, and are not pregnant (Medicaid for lowest‑income populations)

medical_reviewer_approval

Approved at the CHNCT Medical Reviewer meeting following updates including removal of intragastric balloon and one anastomosis gastric bypass from the investigational list and removal of codes from PA review list.

2024-09-27approval

Approved by DSS after initial approvals and clarifications to nutritional counseling and coverage rationale for vertical banded gastroplasty.

2024-09-16committee_approval

Approved by the CHNCT Clinical Quality Subcommittee; included clarifications to the clinical guideline and documentation of ASMBS-endorsed procedures to be reviewed under the policy.

2024-08-28medical_reviewer_approval

Approved at the CHNCT Medical Reviewer meeting for the original publication of the policy in August 2024.

2024-08original_publication

Original policy publication (August 2024) establishing coverage and prior authorization criteria for primary bariatric surgery.